Sentinel Event Analysis

1. A sentinel event is defined by The Joint Commission as an event that results in unanticipated death or major loss of function not related to the natural course of a patient’s condition, or one of several other specifically defined circumstances that do not necessarily result in death or major injury to the patient. The term “sentinel” is used to emphasize the need for immediate investigation and response. (The Joint Commission, n.d.). The abduction of a patient receiving care, treatment and services is one of the specific circumstances The Joint Commission considers a sentinel event.

The sentinel event that occurred at Nightingale Hospital was an abduction of a patient by the non-custodial parent. The patient is a child who had a procedure scheduled. During the pre-operative preparation period, the mother told the pre-op nurse that she needed to leave the hospital to handle something with another of her children. She gave the nurse her cell phone number and asked to be called as soon as the patient was out of her procedure. The patient’s mother left the hospital premises while the patient was in surgery, and when she returned, the patient had been discharged to the care of her father. Staff reported that they looked for the mother after the procedure was finished, but they could not find her and the patient was becoming distraught. At this time, the patient’s father arrived, comforted the patient and the patient was discharged in his care. The discharge nurse reported that the patient seemed very happy to see her father, so she did not see any issues with discharging the patient in his care.

2. Roles of individuals present during this sentinel event:

Registrar: The registrar’s role is to collect insurance and demographic information to register the patient in the system and obtain signatures for admission paperwork, such as consent to treat and acknowledgement of financial responsibility. The registrar prepares an identification bracelet for the patient and ensures that the admission paperwork goes with the patient to the pre-operative area. The registrar stated in her interview that obtaining information about the custodial parent is not part of the process.

Pre-Operative Nurse: The pre-op nurse prepares the patient for surgery by helping the patient get into a gown, ensuring that the identification bracelet is placed on the patient, starting the IV, ensuring that paperwork such as consent forms are complete, performing a pre-operative nursing assessment and administering any ordered pre-operative medications. The pre-operative nurse is responsible for communicating with personnel taking over care of the patient when a hand-off occurs, such as when the patient goes to the OR.

OR Nurse: The OR nurse first receives a hand off report from the pre-operative nurse, then helps prepare the patient for the procedure in the OR, may assist the anesthesiologist in monitoring the patient, and may assist the surgeon by passing instruments. The OR nurse is responsible for communicating with personnel taking over the care of the patient when a hand-off occurs, such as when the patient goes to the post-anesthesia care unit.

Surgeon: The surgeon performs the procedure and monitors the patient’s condition during the procedure. The surgeon is the team lead, and is ultimately responsible for the patient’s outcome.

Recovery Nurse: The recovery nurse receives a hand off report from the OR nurse, and then monitors the patient as they awaken from anesthesia. The recovery nurse monitors vital signs and assesses the patient’s respiratory status frequently; and medicates for pain as needed, according to the physician orders. The recovery nurse is responsible for communicating with personnel taking over the care of the patient when a hand off occurs, such as when the patient goes to the discharge area.

Discharge Nurse: The discharge nurse receives a hand off report from the recovery nurse, then prepares discharge instructions for the patient and/or family. The discharge nurse monitors the patient until they actually leave the facility, and presents the discharge instructions, answering any questions the patient may have.

Security: The security officer was not present at the time of the event, as he was not notified until 25 minutes after the patient was determined to be missing. The officer’s role is to secure the environment and assess the situation to determine whether additional resources are needed. The officer investigates events related to safety and security of patients and staff and makes recommendations for improvements to avoid unsafe or dangerous situations.

Chief Nursing Officer: The CNO was not present at the time of the event. The CNO’s role is to oversee all aspects of nursing care in the organization, and to put policies and strategies in place to ensure that patients are cared for in a safe and effective manner.

3. There are several barriers to effective interaction in the peri-operative area of Nightingale hospital. The different departments seem to work in silos, isolated from each other, and they don’t appear to appreciate the interconnectedness of their roles in providing safe patient care. Based on the interviews, the staff appear to be very task oriented, and have a “not my job” mentality. Almost all of them talked about how someone else should have gotten the information, and some appeared to blame others for the situation. This lack of accountability and ownership of processes and patient care can lead to many more errors and potentially, patient harm. Finally, there is clearly not a culture of communication in the peri-operative area – there appears to be very poor patient handoff communication between patient care areas. An important piece of information, the patient’s mother’s phone number and instructions to call, was not passed on to the next caregiver. Another aspect of the communication issues is that the discharge nurse did not seem to know who her resources were or who to ask questions of when she did not know how to handle a situation.

a. Clear communication among healthcare workers is imperative for safe patient care. The Joint Commission states that breakdown in communication was the leading root cause of reported sentinel events in the USA between 1995 and 2006. (The Joint Commission and World Health Organization, 2007). In an effort to address communication issues, The Joint Commission included patient handoff communication among caregivers as a National Patient Safety Goal (NPSG) in 2007, and has since moved this requirement from an NPSG to a standard.

There are several ways to improve communication at Nightingale Hospital. An important first step is to develop a standard for patient handoff, and second, to ensure that admission documentation for pediatric patients includes information about the parents. Placing identification armbands on the parent as well as the child could be a good policy, and a way for caregivers from one area to the next to ensure that they are communicating with the correct (authorized) person. Another way to improve interactions among the staff is to educate them on the importance of clear communication, set expectations, and hold them accountable.

4. There are several different methods for conducting a root cause analysis (RCA). A good method for this particular RCA would be a fishbone diagram, because it creates a visual diagram that is easy to understand Ishikawa, or fishbone diagrams (so named because of the finished diagram’s resemblance to a fish skeleton) provide a structure for conducting a cause and effect analysis whereby contributing factors are sorted and considered.

A fishbone diagram is done on paper, preferably with a group of involved individuals who can actively contribute to conversation about the event and its causes. The first step is to write the problem in a box on one side of the paper, then draw a horizontal line down the middle of the page, lengthwise (spine of the fish). The first set of “bones” is drawn off of the spine and labeled with major categories of causes. Last, lines are drawn off of these major bones to create minor bones, labeled with the specific contributing factors from each category. Once a fishbone diagram is complete, the information gathered can be used to create an action plan for improvement, based on the specific factors identified.