Sentinel Event
Today we are reviewing the facts on our recent sentinel event, a child abduction. The facts of this case are the custodial parent (the
... [Show More] mother) brought the 3 yr. old child in for surgery. She registered the child and stayed until the child was taken back to surgery. Once the child, Tina, was taken back to the OR the mother left the facility with her other child. She relayed to Greta, the pre-op RN that she would be back when the child was done with surgery with the understanding that the nurse would call if there were any issues or if the child was done earlier than expected. The case went as expected and Tina arrived in the recovery room, but her mother had not arrived back. After finishing in PACU, Tina was taken to the ambulatory post-op area for discharge. The mother had still not arrived back at this time, but the father had arrived. At that time, the father was brought back into the area where Tina was finishing her recovery. After waiting another 30 minutes, the patient was discharged home with the father. The mother received no calls but returned to the hospital to find that her child had been discharged 30 minutes before her arrival. Security was notified and a “Code Pink” was activated. Upon interview by security, it was discovered that the mother and father were divorced, and the father did not have custody. The police were notified and the child was found safe with the father within 30 minutes.
Personnel
There were 8 staff members involved in this case. The first person to see the patient and her mother was Katie Jessup, the registrar. She was responsible for registered the patient, obtained consent for treatment and verified the patient’s insurance. The next staff member was Greta Doppke, RN. Greta works in the pre-operative area was responsible for doing the pre-operative assessment, starting the IV, administered medications, and obtained surgical consent. Greta talked to the mother about surgery and recovery time. Greta then handed the patient off to Rosemary Fry, RN. Rosemary is an operating room nurse and was responsible for the care of Tina while she was under anesthesia in the operating room. [Show Less]