AFT2: RAFT – Task 2
The purpose of this second task is to provide a logical description of a sentinel event which occurred at Nightingale Community Hospital and analyze all aspects of the event. This analysis includes a review of the personnel present, barriers to the personnel being able to adequately complete their job, and how future staff interactions may be improved. In addition, the analysis will review the selected quality improvement approach to be used during the completion of a root cause analysis of the event and what can be done by Nightingale Community Hospital to ensure the sentinel event does not occur again.
A1 – Sentinel Event –
The following is a review by the Nightingale Community Hospital Quality Management (QM) Department of the Pediatric Patient Abduction Sentinel Event Reports provided by the staff with involvement in the event. Description of the Event – Patient Tina, age 3, was at Nightingale Community Hospital on Thursday, September 14, 2013 for ambulatory surgery. At approximately 10:00 a.m. on the same day, Tina was taken into the Operating Room (OR). While Tina was in surgery, her mother left the hospital to run a quick school errand with her son leaving her cell phone number with the pre-op nurse. Following Tina’s surgery, the Recovery Room Nurse paged her mother using the hospital-wide overhead paging system. Tina’s mother did not respond to the page. While in recovery, Tina became very distraught. She was crying and voicing to the Discharge Nurse that she wanted to go home. At this time, the Discharge Nurse was informed that Tina’s father was at the hospital to see her.
The Discharge Nurse stated that when Tina saw her father she was relieved, called him Daddy, and said she was ready to go home. After waiting an additional 30 minutes for Tina’s mother to return, the Discharge Nurse released Tina to her father. When the mother returned to the hospital at 12:30 p.m., she discovered Tina had already been discharged. A “Code Pink” (child abduction) was activated. Tina was found at approximately 1:00 p.m. in the care of her father, who was not the custodial parent. There was no adverse outcome to Tina from the time she left the hospital until the time she was found in the care of her father. Event Policy
A2 – Personnel –
There were many staff involved in Tina’s admission to Nightingale Community Hospital for ambulatory surgery, and her discharge following surgery. This section will focus on the roles of the staff involved in this Sentinel Event. 1. Hospital Registrar – Admission’s Department – Responsible for: Completion all of Tina’s admission paperwork, to include parental and insurance information Parent contact information
2. Pre-Op Nurse – Ambulatory Surgery Department – Responsible for: Completion of Tina’s Pre-Op Nursing Assessment
Getting Tina changed for surgery
Starting Tina’s IV
Giving Tina her pre-op medications and noting those medications on her Medication Administration Record (MAR) Completion of the consent forms required for surgery with Tina and her mother In addition, the Pre-Op Nurse also took down the name and phone number of Tina’s mother who had informed her that she needed to leave the hospital while Tina was in surgery to take care of a school responsibility for her seven year old son.
3. OR Nurse – Ambulatory Surgery Department – Responsible for: Tina’s care while in the OR
4. Surgeon – Ambulatory Surgery Department – Responsible for: Completion of Tina’s surgical procedure
5. Recovery Room Nurse – Ambulatory Surgery Department – Responsible for: Caring for Tina following the completion of her surgery
Overhead paging of Tina’s mother within the hospital once surgery was completed
6. Discharge Nurse – Ambulatory Surgery Department – Responsible for: Reviewing discharge paperwork with Tina and her father
Discharging the patient
In addition, the following staff were also reviewed during the Sentinel Event Root Cause Analysis – 1. Security Officer – Hospital Security Services – Responsible for: Patient Safety
Conducting mock drills to test staff responses to newborn abduction scenarios at Nightingale Community Hospital
2. Chief Nurse Executive – Nightingale Community Hospital Nursing Services – Responsible for: Overseeing all nursing functions for Nightingale Community Hospital
A3 – Personnel Issues –
During the investigation interviews of this Sentinel Event, the following barriers to effective interaction among the personnel involved in Tina’s admission to Nightingale Community Hospital were noted. First, the Admission Registrar, noted that custodial information was not required as part of the admission process. Had custodial parent information been gathered at the time of Tina’s admission to Nightingale Community Hospital, the surgical nursing, medical, and support staff would have known definitively if Tina was to be discharged to her father. Second, the Pre-Op Nurse noted that the Surgeon’s office never provided the hospital staff with any information about the surgeon’s patients from the office. Had the office notes been provided to the hospital prior to Tina’s surgery for inclusion in the medical record, the hospital staff may have been informed of any custodial issues, as well as any medical issues which may have also been addressed while at the office.
Third, while Tina’s mother had given the Pre-Op Nurse her phone contact information, the information was not passed on, or “handed off” to the OR, Recovery or Discharge Nurses. The contact information was also not provided to the support staff for the surgical department. Had the mother’s contact information been shared with the other nursing staff as they were caring for Tina, the call may have been made and the mother may have been at the hospital at the time of Tina’s discharge. The final barrier noted was the delay by the nursing staff to notify the Security Department once it was determined that Tina was missing. Had this contact been made timely, the hospital process to address an abduction would have been initiated much earlier, which may have kept Tina from leaving the hospital grounds with her father.
A3a – Improve Interactions –
At Nightingale Community Hospital, a hand off communication process is vital to ensure the highest quality of care is provided to a patient in a safe environment. The Joint Commission standard Provision of Care, Treatment, and Services (PC), PC.02.02.01, Elements of Performance numbers one and two require that the hospital has a process to receive or share patient information when the patient is referred to other internal or external providers of care, treatment, and services. And, that the hospital’s process for hand-off communication provides for the opportunity for discussion between the giver and receiver of patient information to include the patient’s condition, care, treatment, medications, services, and any recent or anticipated changes to any of these. (https://jcextranetapps.jointcommissionconnect.org/ICMProfile/pages/dashboard.aspx, 2013)
While the detail of a custodial parent would not fit into the definition of the standard above, what would be included would be Tina’s mothers contact information from the Pre-Op Nurse to the OR, Recovery, and Discharge Nurses. During the review of the Sentinel Event, only the Discharge Nurse mentioned the hand-off of communication from Recovery Room nurse about not being able to reach Tina’s mother via the hospital overhead paging system. In none of the interviews following the Pre-Op nurse was it mentioned that the hospital staff involved with Tina’s care attempted to contact her mother via the cell phone number provided. No staff interviewed for the Sentinel Event described the hand off of patient communication to the next service provider. Ideally, the Pre-Op Nurse should have passed on to the OR Nurse that the mother was off site for a short period of time and to contact her on her cell phone once Tina was out of surgery.
The OR Nurse should have then passed on this same information to the Recovery Room Nurse and when Tina’s mother did not respond to the hospital page, the Recovery Room Nurse should have attempted to contact her on her cell phone. If no response, this same information should have then been passed on to the discharge nurse. Once the mother did not respond to the page, the staff should have then passed on the information regarding the need to contact Tina’s mother via cell phone should Tina get out of surgery early. While parent information and marital status is already collected for both parents at the time of a patient’s admission to Nightingale Community Hospital, the addition of a checkbox to the parent information to note which parent is the patient’s custodial parent in situations in which the parents are separated or divorced would have given the hospital discharge staff clear knowledge of who Tina was to be released in the care of.
A4 – Quality Improvement –
In completing the root cause analysis of this sentinel event, a cause and effect diagram (Attachment A) was developed to show the breakdowns in the current communication processes from Patient Registration to Patient Discharge for the Ambulatory Surgery Department. A cause and effect diagram is a graphic tool that helps identify, sort, and display the root causes of a problem or quality characteristic using a structured approach. (http://www.doh.state.fl.us/hpi/pdf/Cause_and_EffectDiagram2.pdf, 2013)
There are a number of benefits to using and displaying information discussed during a root cause analysis in a cause and effect diagram. These benefits include the ability to determine root causes, organize the information being discussed in an orderly manner, helping the review team identify process variations, and may identify areas where data collection may be needed. (Brassard, 1988) Each branch on the diagram notes a cause identified with has contributed in some way to the effect, the Pediatric Patient Abduction Sentinel Event being investigated.
By identifying the specific causes which led up to the Pediatric Patient Abduction, Nightingale Community Hospital will then be able to implement process changes to ensure that the sentinel event does not happen again.
B1 – Risk Management Program –
The following corrective actions will be taken by Nightingale Community Hospital to address the risks identified by the organization in reviewing
current hospital operations during the root cause analysis and completion of the cause and effect review of the processes involved. The corrective action plans (CAP) will note Who will be responsible for the corrective action and ongoing compliance; What actions will be completed to correct the findings; When the corrective action is to be completed; How compliance will be sustained; and the Evaluation Method to monitor compliance with the CAP. (https://www.jointcommissionconnect.org/NR/rdonlyres/8DA0FCB6-DD1C-4CD7-B282-24E880E42D29/0/esc_Compliance_Instructions.pdf, 2013)
CAP #1 – No policy requiring the custodial parent, in the case of a separation or divorce, or a Legally Authorized Representative (LAR) to stay at the hospital or wear a matching armband while a pediatric patient undergoes surgery. WHO – The Registration Department Director will be responsible for the implementation of the corrective action and ongoing department compliance. WHAT – The Registration Department Director will update the Surgery Registration Process Policy to include the designation of the custodial parent/LAR in the registration materials and within the patient medical record. As well as the requirement for the Registration Department staff put an identification band on both the patient and the parent/custodial parent/LAR at the time of the pediatric patient’s admission. The Registration Department Director will also update the Surgery Expectations handout for patients and family members to include the expectation of parent/custodial parent/LAR being required to stay in the Surgery Waiting Area while a pediatric patient’s surgical procedure is taking place. In addition, the handout will also be updated to include the requirement for the parent/custodial parent/LAR to wear a matching armband which includes the name of their child, while on the hospital grounds. The parent/LAR will sign the handout, as well as the Nightingale Registration Clerk.
As this document is in duplicate, a copy will go in the pediatric patient’s chart and the other copy will go to the parent/custodial parent/LAR. WHEN – the update of the Surgery Expectations handout will be completed in one week, September 5, 2013. The training of Registration Department Staff on the new process and handout will be completed by the end of the next week, September 12, 2013. HOW – Compliance with this expectation will be sustained by having weekly audits of 10, or 100% if less than 10,
pediatric surgical patients with a custodial parent or LAR to verify if the custodial parent information is included within the patient record, as well as a copy of the Surgery Expectations handout. The handout must be signed by the parent and a registration clerk.
These audits will be conducted by the Registration Department Director. EVALUATION METHOD – as noted in the previous section, a weekly audit of 10, or 100% if less than 10, pediatric surgical patients with a custodial parent or LAR. Compliance expectation is 100%. Findings will be reported to the Safety Committee for review and analysis. Any weekly report which fall below the 100% compliance expectation will be required to submit a report of performance management action taken with the staff identified in the audit findings to the Nightingale Executive Leadership.
CAP #2 – Surgical Nursing Staff did not complete a full “hand-off” of patient information to the next provider of service. WHO – The Chief Nurse Executive will be responsible for the implementation of the corrective action and ongoing department compliance. WHAT – The Chief Nurse Executive will in-service all nursing staff on the Nightingale Community Hospital Hand-Off Communication Policy. Specifically the expectation for the next provider to have the opportunity to discuss patient information which must include the patient’s condition, care, treatment, medications, services, any recent or anticipated changes to any of these, and any additional information.
This additional information could include where the family is located within the hospital, how to reach them if not in the waiting area, etc. A poster of Hand-Off Communication requirements will be posted in each area of the Surgery Department – Pre Op, Surgery, Recovery, and Discharge. In addition, this hand-off posting will be placed in all areas of the hospital where an exchange of patient information is required. WHEN – The Nightingale Community Hospital Nursing Staff will be trained on the Hand-Off Communication policy within two weeks – no later than September 12, 2013. HOW – Compliance with this corrective action will be sustained by having a monthly audit of 10 surgical procedures to determine if the Hand-Off Communication process is being completed appropriately. The audits will be conducted by Program Monitors within the Quality Management Department.
EVALUATION METHOD – as noted in the previous section, a monthly audit of 10 surgical procedures to determine if the Hand-Off Communication process is being completed appropriately will be conducted by the Quality Management Department. Findings will be reported to the Safety Committee for review and analysis. Any failure to follow required protocol will be reported to the Chief Nurse Executive who will then be required to submit a report of performance management action taken with the staff identified in the audit findings to the Nightingale Executive Leadership.
CAP #3 – No policy requiring the parent of a pediatric patient to “check out” with the Surgical Department at the time of discharge. WHO – The Surgery Department Director will be responsible for the implementation of the corrective action and ongoing department compliance. WHAT – The Surgery Department Director will update the Surgery Discharge Process Policy to include the expectation of the department clerical staff to view the armbands of pediatric patients and their parent/custodial parent/LAR to ensure the information on the bands matches. In addition, the policy will also be updated to include the expectation for the clerical staff to check the parent/custodial parent/LAR’s photo identification to validate they are who they say they are and that the information on the photo identification matches what is in the registration system. Once the information is verified, the pediatric patient and their parent/custodial parent/LAR will sign the discharge paperwork and be allowed to leave the hospital.
The time of discharge will be noted in the patient’s record. WHEN – the update of the Surgery Discharge Process Policy will be completed in one week, September 5, 2013. The training of Surgery Department clerical staff on the new process and handout will be completed by the next week, September 12, 2013. HOW – Compliance with this expectation will be sustained by having weekly observations of 10 pediatric surgical patients to verify if the armbands and photo identification are being checked by the Surgery Department clerical staff prior to the pediatric patient’s discharge. These audits will be conducted by the Surgery Department Director. EVALUATION METHOD – as noted in the previous section, a weekly observation of 10 pediatric surgical patients will be conducted. Compliance expectation is 100%. Findings will be reported to the Safety Committee for review and analysis. Any weekly report which fall below the 100% compliance expectation will be required to submit a report of performance management action taken with the staff identified in the audit findings to the Nightingale Executive Leadership.
CAP #4 – Staff did not notify the Security Department of the pediatric patient abduction timely. WHO – The Registration Department, Surgery, and Security Department Directors will be responsible for the implementation of the corrective action and ongoing department compliance. WHAT – The Registration and Surgery Department Directors will hold a staff meeting with their employees to review the steps to take in an abduction of a pediatric patient, including the timely notification of the Security Department. Upon completion of the training, the Security Department will conduct a monthly Pediatric Abduction Mock Drill with the departments. WHEN – Registration and Surgery Department staff will be trained on the actions required during a pediatric patient abduction within one week – no later than September 5, 2013. The Security Department will conduct its first Pediatric Abduction Mock Drill during the next week, and monthly thereafter for six months.
Following six months of compliance, the mock drills will be conducted quarterly. HOW – Compliance with this corrective action will be sustained by having monthly Pediatric Abduction Drills. These drills will be coordinated and conducted by the Security Department. The mock drills will be set up to test the actions taken by staff, as well as the staff response time. The mock drills will include using patients and parents with appropriate armbands and identification, as well as patients and parents without the appropriate armbands and identification. EVALUATION METHOD – as noted in the previous section, a monthly Pediatric Abduction Drill will be conducted by the Security Department. Findings will be reported to the Safety Committee for review and analysis. Any failure to follow required protocol, including a timely report to the Security Department will be required to submit a report of performance management action taken with the staff identified in the drill findings to the Nightingale Executive Leadership. B1a – Resources –
In this section, the resources required to support the changes proposed in the Root Cause Analysis will be detailed. First, during the interviews for the Root Cause Analysis of this Sentinel Event, the Security Officer and the Pre-Op Nurse each mentioned having identification armbands for pediatric patients and their parents. This simple process of having an identification armband on the patient and their parent/custodial parent/LAR will ensure the patient is not taken from the hospital without one or both parents or LAR having a matching armband. Nightingale Community Hospital could purchase the Sentry Superband below, by PDC Healthcare which could be used on both the parent and the child. The cost is $100.03 per box when you order 1-7 boxes. The price of each box decreases with orders over seven boxes. Each box of identification bands contains 500. Top of Form
Bottom of Form
By having this identification system in place, the surgery department staff members who encountered Tina during her visit to Nightingale Community Hospital each would have known that Tina was not to go with her father as he would not have been wearing an armband. Next, the update of the Patient Registration Paper and Electronic forms, as well as the Surgical Expectations form in duplicate would be completed internally at Nightingale Community Hospital. The Registration Department would complete the update of the paper registration forms, to include the addition of a check off box for custodial parent/LAR. Duplicate paper to print the updated Registration forms and Surgical Expectations handout could be purchased from NCRforms.com at a cost of $389 for 500 full page forms. (http://www.ncrforms.com/, 2013)
Then, the requirement to have a parent or legally authorized representative stay with the pediatric patient while in day surgery would be of no cost to the hospital. The Registration Department staff will verbally discuss this information with the patient’s parent/custodial parent/LAR and note the expectation with the parent/custodial parent/LAR while they are completing the paperwork required for the surgery and the review of the Surgery Expectations. The Registration Department Director would be responsible for ensuring the gathering up of all old forms and replacing with the updated forms prior to the implementation of the updated pediatric patient registration process. In addition, the Nightingale Community Hospital Information Technology Department would complete the addition of the custodial parent/LAR designation in the Electronic Medical Record. As this information will be entered in the record by the Registration Department, the training could be completed at the same time. Second, the revised checklist for hand-off communication among the nursing department will be included in hospital policy at no cost to the facility.
Nightingale Community Hospital could also purchase a book from Joint Commission Resources titled, Improving Communication During Transitions of Care for each department director (12 departments x $75 = $900). (http://store.jcrinc.com/, 2013) Posters of hand-off communication expectations could also be printed within the hospital for minimal cost. Posters would be provided to each department to post where they are most likely to be used. Third, there will be no cost required to initiate the process of checking the armbands and identifications and making a note of the time of discharge in the pediatric patient’s record. No additional changes will need to be made to the electronic or paper medical record to allow for the inclusion of this information, therefore no charges to the hospital. Fourth, the implementation of Mock Pediatric Abduction Drills to test staff response will be implemented at little additional charge to the facility. There will be the cost of staff training and staff time to complete the required monitoring.
The monitoring efforts may also include some overtime as they will be an additional duty for the departments conducting monitoring. The cost for this is noted below. Finally, in all of the actions noted above there is an expectation for staff training. The cost of the required training for Nightingale Community Hospital will vary based on the staff being trained. The cost to train nursing staff will be significantly higher than the cost to train clerical staff due to their hourly salary. In each CAP noted above, training will be completed within one hour of staff time. Therefore, the cost will be figured at – (hourly pay rate for staff attending training) x (# of staff requiring training). In those instances where audits, observations, or mock drills are required, the cost will be figured at – (hourly pay rate for staff conducting the audit/observation/mock drill) x (# of hours to complete). As noted above, it is expected for these activities to be completed in approximately one hour.
Brassard, M. (1988). The Memory Jogger, A Pocket Guide of Tools for Continuous Improvement, pp. 24-29. Methuen, MA.
PDC Healthcare – A Brady Business.
Retrieved on August 26, 2013 from
Joint Commission Resources Store.
Retrieved on September 1, 2013 from http://store.jcrinc.com/
The Joint Commission – Evidence of Standards Compliance.
Retrieved on August 10, 2013 from https://www.jointcommissionconnect.org/NR/rdonlyres/8DA0FCB6-DD1C-4CD7-B282-24E880E42D29/0/esc_Compliance_Instructions.pdf
The Joint Commission – IntraCycle Monitoring.
Retrieved on August 10, 2013 from
Retrieved on September 2, 2013 from http://www.ncrforms.com/
State of Florida, Department of Health – Cause and Effect Diagrams. Retrieved on August 26, 2013 from http://www.doh.state.fl.us/hpi/pdf/Cause_and_EffectDiagram2.pdf, 2013