Root Cause Analysis Due to Sentinel Event free essay sample

Analysis of Sentinel Event: Child Abduction Root Cause Analysis (RCA): Child Abduction Please note the root cause analysis and recommended action plan show evidence of the key components of the RCA matrix for the specific event. An area on the matrix that may not have an identified process breakdown should still be summarized to determine that the component was evaluated. Brief description of event Tina, a 13 year old teenager admitted for day surgery, was inappropriately released to her father when her mother was delayed in returning to pick-up and release the daughter from the hospital. The hospital staff had no awareness of the family situation until the mother came back to the hospital and discovered that her tardiness had allowed the father, against the mother’s wishes, to check Tina out of the hospital. The hospital staff, had attempted to contact the mother multiple times prior to the check-out or release. We will write a custom essay sample on Root Cause Analysis Due to Sentinel Event or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page According to the call logs, six attempts to contact the mother were made by the post-op nurse in the 45 minutes the mother was delayed in arriving. According to the admitting paperwork the insurance for Tina’s day surgery was under the father’s name and policy. The hospital followed standard admitting and release procedures, but was surprised when Tina’s mother did not show or answer her phone. Tina’s father did not indicate suspicion or nervousness, he provided the proper documentation and verification of identity. The daughter confirmed that the gentleman was her father and it was obvious they were comfortable with each other. When Tina’s mother arrived, she was extremely distraught, the hospital contacted security immediately, and a â€Å"Code Pink† (hospital-wide child abduction alert) was activated. The Local law enforcement was also contacted by hospital security and provided the police with the fathers contact information and address. As the hospital security officer interviewed the mother, she shared with him that she and Tina’s father were divorced and that she had full custody of Tina and her siblings. This is not standard information the hospital required at the time of admittance. Within a few minutes phone calls were made to Tina’s father and police were dispatched to the father’s home. Tina was picked-up by local law enforcement within 30 minutes of her mother’s arrival at the hospital. Tina was in no immediate danger, and was resting until their mother could come get her. There were numerous errors that lead to the incident and the CEO of Nightingale Memorial Hospital assured Tina’s mother that this incident would be analyzed and processes put into place to prevent this type of event from recurring. Who participated in the sentinel event root cause analysis? Nightingale Memorial Hospital has a rotational committee that consistently is represented by the following departments: * Board of Directors – usually Assistant to the Chief Operating Officer * General Services Lead from Department Effected – Oncology, Pediatrics, Maternity, etc. * Patient Services * Admissions * Nursing Staff Those participating in the review are listed below: * Assistant to the Chief Operating Officer * General Services Vice President of Security * General Manager Pediatrics Department * Patient Services Department Administrator * Director of Admissions * Lead Nursing Sta ff – Pediatrics / Maternity Specific Task and Assignment of Sentinel Review Committee The purpose of the review committee is to evaluate the parental abduction sentinel event which occurred on September 14. Provide and accurate investigation as to the base reason(s) of how and why the abduction occurred or was allowed, and provide recommended action items and 30 day monitoring to establish and recommend a policy or system improvement to prevent an event of this nature from occurring again in the future. When deficiencies are noted, hospital leadership should establish task forces, made up of professionals from all relevant disciplines, to analyze existing processes and recommend interventions that might improve weak processes. Without multidisciplinary and interdepartmental communication, it is difficult to understand the big picture—what is actually happening to the patient during the episode of hospitalization and what the impact on the organization is. Teams led by department leads can brainstorm data for better ways to communicate and recommend preventive strategies. The task force team should consist of surgeons, anesthesiologists, risk control specialists, operating room nurses, quality management staff, and research analysts. Medical staff can explain to the team how complications from miscommunication or poor labeling have an impact on the patients health and require expensive resources such as operating room or intensive care unit (ICU) admission. A member of the risk management department might report on how much miscommunication or poor labeling costs the organization in malpractice claims and lawsuits, and someone from utilization might explain how much miscommunication or poor labeling costs the organization in excess days of stay. Someone in public relations might explore how poor publicity has had an impact on the volume of patients. Too often people in one department do not communicate with people in other departments. The medical records of patients who experienced the sentinel event should be analyzed by the team. Once the underlying causes of the event are identified through root cause analysis, the team should develop protocols to improve faulty processes. The team should research available literature to adapt to whatever might be useful to the organization. A tremendous amount of knowledge has already been published. Senior leaders, such as the CEO, COO, and CFO, should be involved in the improvement effort because they need to understand the organizational implications of improving processes—professional time and additional financial outlay may be needed. Measures should be developed to track the changes in the processes, and staff designated to collect and document the data. Databases, which may be Web based, should be developed to track analyze the rate of change and the implementation of preventive strategies by physician, unit, division, or patient population. When did the event occur? The sentinel event occurred on September 14, Thursday at 12:30pm right at the end of the morning swing shift with multiple staff occupying the pediatric wing and afternoon crew getting up to speed with the morning’s activities. The surgery was scheduled two weeks in advance and the entire pediatric department had known about the surgery prior to Tina’s arrival, from Monday’s Staff coordination meeting. What area/service was impacted? The following departments are listed in alphabetical order with a brief summarization of the department’s role and responsibilities. It is believed that all departments listed below will be impacted and addressed by action items from this investigations in future interactions with the patient and each other. Admissions – documents and records the patient’s personal information and receives consent forms before being directing the patient to a specific area in the hospital unit or ward. General Services- includes services provided by departments such as portering, catering, housekeeping, security, health ; safety, switch, laundry and the management of facilities such as parking, baby tagging, access control, CCTV etc. General Surgery covers a wide range of types of surgery and procedures on patients. Health ; Safety promotes and maintains the highest possible degree of health and safety for all employees, physicians, volunteers, students and contractors, and actively participates in quality, safety and risk initiatives. Human Resources provides a professional, efficient and customer focused service to managers, and staff, and facilitate the delivery of professional, efficient and customer focused service to patients. Information Management – specializing in quality management, continuous quality improvement and peer review by improving the quality of information. Maternity – indirectly affected by the action items of pediatric division as they provide antenatal care, delivery of babies and care during childbirth, and postnatal support. Neonatal indirectly affected closely linked with the hospital maternity department, as they provide care and support for babies and their families. Patient Accounts answers all billing questions and concerns, requests for itemized bills, and account balance inquiries. The patient accounts department also assists patients in their insurance benefits for services rendered. Patient Services – is commonly a source of information that can channel patient queries in relation to hospital services to the appropriate departments. Pediatric Services – specifically the area within a hospital specializing in the care of critically ill infants, children, and teenagers. What are the current steps in the SURGERY process, as designed? (Flow Diagram(s)) Patient and Parent arrive at the hospital on the scheduled day, at the specified time. After stopping at the Admitting Office to verify information, patient/parent are escorted to the childs room in the Pediatric Unit. Nurses check the childs weight, pulse, temperature and breathing, and give him/her a hospital gown to wear to surgery. In the Surgical Area, the surgeon and the anesthesiologist asks the parent more questions. To avoid a separation that could be frightening to the child, parents of children over six months of age are permitted to accompany them into the Operating Room and to stay until the anesthetic takes effect. The parents are then asked to wait outside the OR in a nearby adjacent waiting room. Hospital encourages parents to stay in the hospital by inviting them to have a snack in the Cafeteria or Coffee Shop while the child is in surgery. Parents are then reunited in the Recovery Room immediately after the operation. Parents are provided a beeper so that they can be notified immediately when surgery is over. The child will be in the Recovery Room until she is awake enough to return to his/her room. There, post-recovery care will be provided along with any instructions parents will need to care for her at home. Note Standard Warnings to Parents of Child behavior post Surgery: Parents are instructed the child may be wide awake and alert right after surgery, or may be groggy for a while. Parents are encouraged to discuss any questions or concerns with the nurse or anesthesiologist. Simplified Flow Chart Parent Registers Child at Admissions Hospital communicates arrival of patient to Pediatrics and/or General Surgery to department and provides direction to patient Child receives ID bracelet that is matched with parent or guardian at check-in Parent and Child taken to pre-op areas by RN and prepared for surgery (pre-op assessment done and consent signed) Parent usually accompanies child to door of OR suite Parents instructed to wait in adjacent waiting area until surgery complete given a beeper Post op, child transferred to recovery area Once stabilized, parent and child reunited Discharge instruction completed and child is discharged with parents once recovered Discharge includes escort to common area of hospital through security area of pediatrics division Potential for Child Abduction in Pediatrics/Maternity This flow chart of cause and effect was analyzed for child abductions in Maternity and Neonatal care and generically identifies potential abduction threats of children and potential weakness that allow an abductor to leave with a child. However, the investigative review of pediatrics specifically the sentinel event, has further assigned action items that are to be implemented in addition to those stated and currently a focus in this flow chart. What human factors were relevant to the event? Opportunities for error exist in every task performed by a nurse, physician or any other healthcare employee. Even though a single task may never be performed exactly the same way twice, minor variations in performing a task are usually of no concern. However, when a sentinel event occurs, it is considered a human error. Human error is any human action or inaction that exceeds the tolerances defined by the system. In this case Tina was unintentionally, released to her father when he did not have custody of the daughter. From the hospitals investigation, human error will be evaluated from the point the child was brought back to the recovery room post surgery. However, the hospital recognizes human error may be significant from a point prior; in that the mother was allowed to leave the hospital without a way of contacting her. As mentioned above two types of human errors exist: Unintentional and Intentional. Unintentional errors are simple mistakes that were not considered prior to the action for example bumping a switch or not labeling a bottle. Intentional errors are the actions deliberately committed because workers think their experience or judgment is correct or better than standard prescribed hospital procedures. This is often the case when short-cutting occurs to speed up a process. ie. Release of the patient to the wrong parent. Without assumptions, the evaluation process has traced the beginning of the event to the waiting and recovery period (postoperative). The mother had not provided any previous notice to the hospital that her daughter was not to go home with the father. This was no fault of the mother of the child, the hospital recognizes that it has no in-advance survey or questionnaire for that type of information prior to the signature of the release waiver. According to the investigation and testimonials; the mother was in a hurry to take one of Tina’s siblings to an offsite event, and assured the staff that she would be back on time. Human error on the part of the hospital staff, allowed the release forms to go unsigned until the mother could return. Coincidently, the father arrived shortly after the mother had left. There was no apparent intention to remove the child at that time. Upon completion of the surgery and a good portion of the recovery, he offered to take her home when the hospital couldn’t contact the mother almost an hour later than she said she would be there. His information matched the information provided on insurance submitted for the child’s surgery. The staff performed all regular procedures, prior to the release of the child. Which leads the committee to believe it is an error in the system that needs to be corrected to prevent a similar event from occurring in the future. The staff intentionally accommodated the release of the child to speed up the process of release. The staff had been trained and was well aware of the release process but allowed the father to leave with the child even though the mother had not signed the standard waiver. The thought process behind the event was based on a allowed Housekeeping to clean the room and prepare for two other children that were to be coming out of surgery within an hour. This hurried release of the patient ultimately was the human error that created the event, although other unintentional errors were made previously. How could equipment performance affect the outcome? The only equipment performance that was involved in the release of Tina to her father was Security Monitoring of the check-out from Pediatrics and the un-matching ID bracelets. This was purposely, overridden by the staff that checked out the patient and escorted the parent and the child through the security area. As an afterthought, the hospital has local beepers that work within a 10 mile radius of the hospital campus, a long distance â€Å"beeper† should have been issued to the parent when she left the hospital. An uncontrollable equipment issue; was the problem with the mother’s cell phone not functioning properly, whether battery or reception, the hospital should not have relied exclusively on the mother’s cell phone for their only ommunication with the absent mother. What controllable factors directly affected the outcome? * Staff to confirm communication with the person with matching ID bracelet prior to release. * Staff not to allow a parent to leave the facility prior to addressing â€Å"Release Intent Form† * Staff to provide other accommodations for waiting outside of the recovery room to expedite housekeeping * Securit y should have questioned missing ID with nursing staff prior to release * Security to verify vehicle and contact information and destination. Staff should have issued a â€Å"Redi-Beeper† to the patients mother * Release waiver was signed by someone other than the person who checked the daughter into the hospital * Further questioning of father and daughter independently to verify family status prior release Were there uncontrollable external factors? Uncontrollable external factors are those factors that the organization cannot change that contribute to a breakdown in internal processes. An organization should not be willing to assign many issues to this category. Although a factor may be beyond the organization’s control, the organization may be able to minimize the factor’s effect on patients. * Father coming to see daughter was outside the hospitals control. * Mother’s cell phone not working was not anticipated * Conflicting schedules (surgery, siblings event) * Mother’s tardiness (potential need for secondary contact or way of communication. ) * Patient insurance coverage authorized by non-present parent. What areas or services that were impacted? List all other areas that have the potential for a similar event to occur. This will assist in implementing risk reduction strategies in other pertinent high-risk areas. As noted above the sentinel event is the abduction of a child- in this case it was to a non-authorized parent, but the impact of the study includes potential threats in both maternity and neonatal care also. * Inpatient units * Any ancillary/clinical department that may separate parent from pediatric patient * Although harder to monitor, there is a potential for abduction for children waiting for their hospitalized parent(s) to come out of surgery. To what degree is staff properly qualified and currently competent for their responsibilities? Report is to identify and include all staff present, not just specifically those assumed to be specifically involved with the event. Part of the investigation is to determine if staff was formally trained to perform the specific duties or tasks involved in the event. Was the training adequate? Is staff training and competencies documented? Have procedures and equipment been reviewed to ensure a good match between people and tasks performed? Was there staff management issues involved in the event? Was there unfamiliarity, with procedures/equipment? Was float staff from another area assisting? Was staff oriented to the organization and department specific policies/procedures? Staff levels were appropriate for the shift rotation, the pediatrics division is typically staffed with 15 employees: four doctors, eight RN’s, and two admissions and or clerical staff. All surgeries had been scheduled two or more weeks in advance, staff were aware of and familiar with their responsibilities. Just prior to the release of the 13 year old, a single new nurse which had been with the hospital for over two months but was still in training, started his shift but had no interaction with the patient because of the extra demand for preoperative patients due to a call in sick from another nurse. All staff training records were examined and reviewed to show appropriate levels of training and understanding of the admissions process and the check-out procedure and release. The only staff management issue was the shift rotation during the recovery process of the young lady. Currently, the hospital does not have a process in place to verify family or custody rights in the release of a patient. This has always been addressed with the release waiver signed by the parent once the patient goes into surgery. From the hospitals perspective: all staff were fully trained and performed according to established protocol. * No process in place at the time of incident to provide guidance to staff to directly prevent such an incident * Staff had been appropriately oriented to the department/organization and did not have any performance issues. How did actual staffing compare with ideal levels? The staffing levels at the time of the event were adequate to address the required workload. On scheduled surgery days typical staffing is four doctors, nine nurses, and two admission staff. As stated above only one deficiency was noted in desired staffing levels. A single nurse called in sick, but typically nine nurses allows for one floating nurse to fill in as needed. Document the actual staffing in area of occurrence versus planned staffing according to the staffing model. Explain any variation; higher or lower staffing. Pre-op: Staffing model requires four RNs and one unit secretary that is shared with post-op side. Actual staffing was three RNs which resulted in pre-op nurses prepping additional patients than usual. * Post-op: Staffing model requires four RNs with the shared unit secretary. Actual staffing was three RNs. What are procedures for dealing with contingencies that reduce effective staffing levels? The following narr ative outlines the results from the investigation of employee, team lead awareness, and current procedures in place to deal with staffing deficiencies. From the investigation there was not a deficiency in staffing levels. Two nurses need to be absent for additional staff to be brought in during a shift. This is to be determination is made by shift coordinator and head nurse. * In the review, all staff are fully aware of the organization’s policies and procedures for dealing with patients when there is an absence, * The hospital maintains appropriately detailed, accurate, and up-to-date staff needs and records within all departments and staff, * Each department identifies and anticipates any high demand situations or other potential causes for concern when a known absence occurs and requests elp from other departments when critical. * Plans are in place to use float pool nurses, contact part-time staff for extra hours, or reassign staff from other units. Again, from the review the error was not caused by a shortage in staffing, if anything it was a shortage in available recovery rooms. Two additional patients were expected to be completed with similar surgeries, and would be in need of the recov ery area within an hour, the staff recognized the shortage of space and potential problem with the mother being delayed over an hour beyond the necessary and expected recovery of her daughter. The pressure on the staff was limited space – the staff was accustomed to working with these issues and would have made other arrangements had the father not been there ready to release the daughter. There was not a release consent waiver signed prior to the operation due to the hurried departure of the mother that would indicate the desired release procedure of the daughter. The with verified identity matching the insurance submittal, the staff made a judgment call and allowed the daughter (asking her permission) to be checked out in the father’s care. Neither the father nor the daughter, were apprehensive about the decision. Performance History of the relevant processes? When was the last assessment performed? In the sentinel event of a non-custodial parent abducting a child the staff has not been evaluated previously, this is the first record of an incident with this department. The hospital has policies for maternity threats but has a more relaxed approach with teenagers that can communicate their intents and positions. * NA—No process in place at the time of incident to provide guidance to staff to directly prevent such an incident How can orientation and in-service training be improved? All staff was oriented to the job responsibilities, organization, and policies and procedures regarding safety, security, hazardous materials, emergency, equipment, life-safety, treatments, and procedures? Are policies revised/updated, evidence based, and readily available? Have policies or procedures changed without providing additional training? Was a new policy developed and staff training conducted? Do float staff or agency staff receive training within the areas they are assigned? Is this documented? It is recommended that a â€Å"A Guide for Parents† be posted on the internet and made available in the Pediatrics wing regarding preparation for surgery. It should outline preparations parents can make to assist with pre and post surgery procedures. Parents play a key role in caring for a hospitalized child. They are the most important person to a child. Make the parents an essential part of the health care team. The hospital should encourage parents to participate actively in the childs care and teach them how. This would lead into an excellent way to interview parents and discover release preferences of the custodial parent, and have them confirm those preferences in writing by signing the release waiver as they are preparing for the surgery. Especially, in the Pediatrics department typical teenagers are concerned about what will happen to them in the hospital. The staff should encourage teenagers and parents to ask questions and feel comfortable to talk directly with the nurses and doctors. The staff should include the teenager in all discussions or decisions about his/her care. Establish a series of 5 or 10 questions in a casual interview format that directly ask who will be responsible for the pickup and checkout of the patient, review the questionnaire with each patient to minimize errors, and keep the record as part of the patients medical file. A Guide for Parents could include topics like: A bulleted checklist to follow Preparing Your Child for Surgery Schedule a preoperative tour Preoperative tests Day before surgery What to bring to the hospital Day of surgery What to expect Separation and Recovery Check Out Procedure Staying overnight with your child Visiting/ Visitors At home care By creating an expectation and checklist readily available to the parents with an encouraged role as part of the healthcare team, it will allow the hospital work with better direction from the parents earlier in the process to ensure something similar does not occur in the future. This approach will require minimal investment, web page updates and brochures, and minimal updates to staff training, but should have significant impact on the department and discover answer to family and procedural questions early in the care and hospital planning. To what degree was information available when needed? The nature of this event was typical to most day operations, in that the medical record followed the patient from check-in to release. All information was readily accessible, with the exception of the standard â€Å"release consent waiver† that should have been signed prior to the mother leaving the hospital. Since our transition to electronic medical records – the missing form was even caught and highlighted by the system and was signed by the father in the absent mother’s place. The information on record was accurate and available electronically fast, and verified by the system. Was the level of automation appropriate? The only area of automation that was activated in the release of the child to her father, was the security device on her wrist did not correspond to anything the father was assigned in the waiting or recovery room as a visitor. The automated security check-out did catch a singular ID but this was overridden by the nurse in escorting the child through the security area. To what degree is communication among participants adequate? The hospital has procedural form of communication that is quite comprehensive. When staff communicates between each other or the patient the intent is to clearly identify the Situation, Background, Assessment and Recommendation (SBAR). It is a simple, effective way to communicate a large amount of information in a succinct and brief way, even in an emergency when a patients situation is escalating. When the communication format is effectively understood and used it improves the intended communication and speeds reaction toward the next step in the care of the patient. In the review of the sentinel event and the child abduction the following communication was traced and evaluated Physician to Patient/Parent, Nursing Staff, and Departmental Lead. The Physician had very little interaction with the staff in the release of the child to the non-custodial parent. The Physician had met and associated with the mother prior to the surgery, and briefed the father once the child was in the recovery area. This is not an uncommon scenario for the physician to interact with different parents before and after surgery, with complicated and hectic family schedules. The Physician was well informed of the surgery and had been introduced to the patient the day prior. The nursing staff and department lead worked well with the physician and communicated openly and freely about the timing of the recovery of the child and the pending upcoming surgeries. When the mother was delayed, again it was communicated openly among staff the need to relocate the child quickly to a different area once the child recovered sufficiently to allow room for two other surgeries, time in the recovery area. Nursing Staff to Patient/Parent, Departmental Lead, Physician, and Security. The Nursing staff interacted with the patient/ parents, doctors, and departmental staff. From the investigation- Nurses played a pivotal role in the release of the teenage girl to her father. They were problem solving and communicating amongst themselves about a solution. The teenager and father perceived a problem with the timing and recovery arrangements and wanting to help, offered a simple solution to the problem. The solution was discussed among the staff and was resolved that the release would be appropriate. Again, because of the missing â€Å"consent release form† there was no procedure in place that prevented them from releasing the child to her father. In this situation, there was no other communication identified between a department technicians, volunteers, pharmacists, or other departments (ie. security) with the pediatric staff or the patient or parents. Was the physical environment appropriate for the processes being carried out? The investigation looked closely at the environment the patient was in or was transferred to/from. Spaces, privacy, safety, and ease of access are a few items being considered. The pediatrics division is always busy and requires well planned logistics and scheduling to meet the needs of its patients with limited resources and space available. When unexpected delays in the process occur, space becomes the bottleneck for the hospital efficiency. This was well known to the staff and was a primary reason the decision was made to release the child to the attending parent. The nursing staff is restricted on the amount of room available in the recovery area, especially for day surgery patients. Those patients requiring overnight or long-term care are assigned a room and are moved to that area as soon as the recovery is adequate, freeing up the space in the recovery area. In this scenario, the mothers delay was creating a bottleneck in the recovery area, with impending pressure of two soon to be completed surgeries. The potential for this type of situation is highly likely to occur again or be repeated with current process and space resources. What emergency and failure mode responses are in place and tested? In review of the sentinel event, the appropriate safety evaluations and disaster drills were properly conducted. The immediate response from security and local law enforcement worked as planned. Response was timely and information was readily available from the check-out procedure to identify the location and contact information of the father. â€Å"Code Pink† drills in conjunction with local law enforcement are done sporadically and not on routine basis. This is to ensure proper response of new staff, act as a refresher for staff familiar with the alert and maintain efficiency with public departments outside the hospital. The recovery process of the abducted daughter was resolved easily, because the father went directly to his destination and was honest with the hospital staff. The potential for an alternative outcome was extremely high if the father’s intention was to bypass or manipulate the system and then try to avoid discovery or cooperation with the police. The investigation shows that the staff verified the identity of the father, the address, and contact information prior to release. This was by far the biggest help in the recovery of the abducted daughter. To what degree is the culture conducive to risk identification and reduction? The overall culture of the facility encourages and welcomes change, suggestions, and warnings from staff regarding risky situations or problematic areas. Management actively establish methods to identify areas of risk or access employee suggestions for change. As from the event the CEO was involved directly in the recovery and promised the mother the situation would be evaluated and reviewed to prevent a situation similar from occurring in the future. A member of the Senior Leadership group, including the CEO, participates in meetings related to serious adverse events. * Senior Leadership and department management encourage staff to bring opportunities and suggestions forward that would improve patient care and the work environment. * Senior leadership and department management all are active in patient safety rounds and encourage open discussion of patient safety issues among staff. What are the barriers t o communication of potential risk factors? The organization as mentioned above implemented a strategy of communication among staff through training and advertising. The hospital has established a specific protocol to remind nurses what to assess and how to communicate information quickly and effectively to physicians and each other. A nurse starts by assessing the situation and providing a concise statement of the problem, background on what has happened, then provides a quick assessment of what they assume the problem to be, and then makes a recommendation to the physician or party involved. As a standard protocol, reminders have been posted throughout patient rooms and departments. By having this criteria listed in specific locations, nurses are reminded of the immediate steps to quickly determine if the patients situation needs. This structure of communication has empowered staff as they assess patients and provide critical information to physicians and families. Adverse events and serious errors are possible in pediatric care, and typically factors in the work environment are key predictors of adverse outcomes for patients. Communication between nurses and physicians may be the most significant factor associated with patient outcomes. From a survey taken from out patient data; when staff worked well together and communicated in a healthy work environment patient outcome was far superior, then at times when there were dysfunctional or adversarial relationships among staff. This finding indicates that the hospital is improving culturally and is currently working with a cohesive team that communicates well with each other. Statistical data indicates improved patient outcomes and fewer critical errors of supportive staff. Although the event occurred and is a potential risk for the future, the investigation feels the hospital staff is open to change and correction to prevent a similar occurrence from happing in the future. How is the prevention of adverse outcomes communicated as a high priority? From a recent departmental and overall hospital survey, leadership is involved actively to develop a culture of communication and problematic avoidance. Hospital leadership has indicated a supportive communication culture is not measured by how many communication policies or procedures are in place but by how clearly employees understand the organizations mission, by how well they are treated, recognized and respected and by how committed the hospital is to enhancing the value of their employment experience. The leadership of the hospital has gained many insights into the value of communication during the past five years with the new administration. Communication is a key factor in decision-making, in the development of new initiatives and in managing human resource issues. The hospital is cooperatively affiliated with the community and provides leadership in patient care, teaching and research, and believes that ongoing communication is developed culturally and is intrinsically woven into staff training and problem solving approaches. This is an important part of the organizations mission. * A confidential suggestion box and hotline have been established to report high-risk issues and each of these are read and evaluated by the Patient Safety Officer. Corrective actions are taken on a regular basis. * â€Å"Patient Safety† is one of the organization’s values. Hospital administration distributes a quarterly newsletter providing recommendations. The newsletter outlines supportive data regarding outcome deficiencies, and then identifies critical awareness issues. High risk issues are highlighted and addressed regularly. Summary of Investigation – Root cause and Action Items The following narrative is essentially a list of determined r oot causes for the sentinel event occurring on September 14, regarding the unintended release of a child to a non-custodial parent (potential for parental abduction). The investigation has concluded the system was weak at three critical points: * Family Orientation and Cooperation * Backup Communication/Security Plans * Spatial Needs of Division Family Orientation and Cooperation The first weakness is a parental orientation and cooperation. The hospital has had a culture of providing what the patients needs and isolating the interaction with the rest of the family and not integrating their interests and care in the recovery of the patients. This culture is changing and more responsibilities are being shared by the families both within and without the hospital. This cooperation requires more open communication, teaching or training, and communicating using layman’s terminology as the hospital educates families, but the result has been less stress on staff, better community relationships, higher profitability, quicker recoveries, and higher patient morale. Efforts are being made to educate parents and families how to prepare and maximize resources when visits are scheduled and organized, which minimize impacts on the hospital and the families. Recommended Action Items include internet and brochure printings for families to review prior to their hospital visit, interviewing the parent(s) at the time of patient admission as part of the family integration, issuing a security device and establishing an exit plan in advance. Backup Communication/Security Plans The problem that caused the event was the mother became unreachable via the cell phone while she was away from the hospital. The hospital had made multiple attempts to contact her when she was not present during the recovery. The father was involved immediately from the time the daughter was brought out of OR. Had the hospital issued the mother an optional â€Å"beeper† there would have been a secondary or backup way of communicating to the mother, that the daughter had successfully finished surgery and created an urgency to either return to the hospital or communicate back with the hospital. The pediatrics division has resolved to issue a fully charged â€Å"beeper† as standard procedure in the event that a parent or guardian leaves the child unattended at hospital. This event has caused the review committee to evaluate other potential weaknesses in the hospital system and included security awareness and involvement to be reviewed in both maternity and neonatal care, in addition to general surgery and pediatrics. Security ID bracelets will be issued to authorized family– in order to track patients and families and distinguish visitors in the hospital. A security / and housekeeping checklist will be developed to assist families exiting the hospital. The list will include a review of belongings and security review prior to checking out and leaving the hospital. All standard check-out procedures will be completed through a single area, any exit activity outside of the main area will notify security and close alternative exits from the affected areas in the department. Staff ID badges will continue as an override to the lock but will secure the area to unauthorized personnel. Code pink drills will be performed quarterly (in first 10 days of the second month)for the first year and semi-annually each year following unless changes are made to the alert system. In that event, the training and drill testing will revert to once a quarter schedule for the first year and then semi-annually thereafter. Spatial Needs of Division This event has caused the review committee to evaluate spatial needs based on physician’s schedules and standard surgery days within the hospital. The hospital sees two solutions: either schedule fewer surgeries more times in a week, or expand the recovery area to have a 20 percent larger capacity for day patients. Although the doctors have expressed a negative perspective of adding another surgery day, the logistics prove to be the best for the resources the hospital has to work with. A cap of six surgeries will be erformed on each Tuesday and Thursday with one space cautiously reserved on Thursdays for patients that miss appointments or have schedule conflicts. Currently, up to 10 surgeries are scheduled between three doctors on Tuesdays only. This should improve the use of hospital resources and relieve pressure from multiple surgeries ending within very close times of each other – resulting in patients requiring the same resources at the sa me time. The original schedule of surgeries is based on a time when the hospital was much smaller and did not perform as extensive of care for children. The expansion of the department has helped the review committee realize the need for better logistics and resource usage. There is definitely potential for expansion of the pediatrics division but this will be addressed over the next three years with future growth plans and resource development. In addition, to better logistics and spreading out surgery schedules, the hospital is evaluating a contingency plan that accommodates an emergency need for additional space. A pediatrics and committee is evaluating needs for additional space and will report back to the executive committed in next month’s board meeting. Narrative Summary The hospital was fortunate that the child abduction was minor and easily resolved, but in review of the processes and events that lead to the occurrence, the review committee has evaluated very important steps in the system that should improve the hospitals ability to prevent a similar event from occurring in the future. A breakdown and analysis will be outlined and simplified in an action item matrix on the following pages to the end of the report. Similar strategies will be evaluated and implemented for other areas of the hospital but the primary focus for Child Abduction Sentinel Events is in the pediatrics division, please not all locations of implementations will be performed in the Pediatrics group. It is anticipated that families will become more involved and better prepared as the hospital educates them through the process and expectations for a successful experience. As staff becomes more trained and cooperative with the families it is anticipated that customer satisfaction will be increased in pediatrics and Admissions. Although there still exists a potential for departmental staff overrides, security will be able to interact and record those occurrences more readily. These simple action items are fairly cost effective and will have exponential returns for the hospital as they become proficient and implement the tools.