Healthcare: Root Cause Analysis

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Sentinel event at the Nightingale Community Hospital involved a child abduction incident on September 14^th, 2010 at 12.30 pm. Tina was scheduled for a minor operation at the hospital which would last approximately 45 minutes. Tina’s mother soon left to attend to a domestic issue after her daughter went to the operating room. She returned after two hours to take Tina home and discovered that her daughter was discharged 30 minutes later. The mother was enormously distraught, prompting security to be summoned. The local law enforcement later discovered that Tina had been taken by her father to his home to wait for her mother. The CEO of the hospital promised Tina’s mother that the occurrence would be analyzed and measures set up to prevent such an event from happening again (Sentinel Event, n.d., p.1).

The roles of medical staff during a sentinel event are critical to the wellbeing of the injured patient. In the advent of a sentinel event, the Chief Medical Superintendent (CMS) must be informed of the incident immediately. The doctor on duty must also be notified if the sentinel event involves a patient. In case a patient is hurt in a common area, such as an elevator, sidewalks, or waiting room, the security personnel at the hospital must complete a Sentinel event report (Manohar, 2008, p.4). For instance, those who participated in the analysis of the child abduction incident on September 14, 2010, at Nightingale Community Hospital included: the security; Registrar; Pre-Op nurse; Chief Nursing Officer; O.R. Nurse; Surgeon; Discharge Nurse; and Recovery Nurse. The incident affected a number of hospital services such as the security services, discharge unit, Registrar unit and human resource department.

There are several steps to be followed before a child is admitted at Nightingale Community Hospital. On arrival, the parent registers the child at the Registrar section where the demographic and infant information is captured. In Tina’s case, the Registrar did not capture information about the patient’s custody because it was not part of the hospital’s standard procedures. The child is taken to a pre-op section where the Pre-Op nurse conducts the pre-op assessment, changes the patient into a hospital gown, and administers the pre-op medicine. The parent is allowed to accompany the child to the door of the Operating Room suite to wait. After surgery, the child is transferred to the recovery area to regain consciousness. Once the child is stabilized, the parent is allowed in the room. Finally, the parent is taken through discharge teachings then allowed to leave with the child.

There were several human factors that contributed to the incident at the hospital. First, the security was not informed about the kidnap incident immediately (the security learned about the incident 25 minutes later). Second, the Registrar did not bother to ask the mother about custody information of the child because it was not part of the hospital requirements. Third, the lack of effective communication between different departments played a major role in Tina’s kidnapping incident. Fourth, professional malpractices by nurses in the operating room were also evident. For instance, the nurses ignored collecting information on custody of the child from the surgeon’s notes. Finally, security and discharge did not bother to inquire whether the father had permission to take Tina home.

There were a number of controllable factors that the hospital can implement to mitigate the recurrence of a similar incident. For instance, the hospital needs to establish policies that are consistent with other departments. The infant abduction drills should be expanded to include child abduction drills to improve the Security’s response to sentinel events. In addition, the parent and the child should be issued identical wristbands, decoded into the security system and main doors to monitor the movements of the children. Nurses should also be vigilant and ensure that children are handed over to their rightful parents. Improved modes of communication should be introduced and all staff members need to know that what happens in one department has a serious implication on the role of other departments. It is also worth noting that some uncontrollable factors played a role in the child abduction incident. For example, the lack of a screening process in the hospital cannot prevent unauthorized persons from accessing the facility.

Other areas have the potential for a similar incident to occur. These include waiting for the lounge, stairs, inpatient units, and other clinical departments that are separate from the pediatric wing. The fact that this was the only sentinel event ever recorded at the hospital testifies to the fact that employees were properly trained to meet their obligations. However, there were isolated cases of unprofessional conduct such the nurse ignoring vital information about Tina’s custody status and lack of effective communication amongst staff. Moreover, the hospital standard procedures did not capture information about custody rights about patients. The absence of screening process at the time enabled Tina’s father to gain entry to the facility. Moreover, the actual staffing was less than the ideal level. For example, the Pre-op staffing model requires four RNs and one unit secretary. However, the actual staffing level at the hospital was three RNs which stretched the pre-op resources. The Post-op model requires four RNs but the actual number at the hospital was three RNS. To address this shortage, the hospital has plans to introduce contact part-time staff, float pool nurses and reassign staff from other departments to enhance service delivery.

According to the Joint Commission, poor communication among medical personnel is a major contributor to medical errors in many healthcare institutions (Daniel & Rosenstein, 2005, p.1). Although the surgeon’s notes had information on Tina’s custody, the nurses in the operating room were not aware of it. Each department at the hospital is only concerned about its own interest hence there is little understanding amongst these departments about the significance of roles of each department. The kidnapping incident occurred because of sporadic “Code Pink” drills performed at the hospital. According to the security officer interviewed, the hospital did not perform child abduction drills. It only performed sporadic infant drills to test the response to sentinel events. Hierarchical structures in many hospitals also prevented the flow of information amongst medical staff (Daniel & Rosenstein, 2005, p.5). Granted, the safety of patients depends on how doctors and nurses relate when on duty.

Priority focus Areas (PFAs) refers to procedures and structures in a health care institution that drastically impact the quality and safety of patient care. These guidelines should be used to assess standard conformity with respect to patient care. Assessment and care Services must involve the implementation of a sequence of processes that include: assessment; treatment services; healthcare provision; ongoing re-evaluation of care; and discharge planning. Assessment and Care services are mobile in nature to take care of patients’ needs while in a healthcare setting. Thus, successful execution of improvements in Assessment and Care Services depends on the full support of management. Quality Improvement Activities identifies the collaborative methods to the continuous upgrading of the procedures that provide health care services to fulfil the need of patients under care (General Joint Commission, n.d., p.2).

Quality Improvement depends on comprehending and modifying procedures on the basis of knowledge and data concerning the procedure themselves. It encompasses recognizing, measuring, executing, measuring, monitoring, planning and analyzing procedures to make sure they are functional. Examples of such actions include: devising a new service; creating a flowchart of a clinical procedure; gathering and analysing information about patients’ outcomes and selecting areas that require special attention. Communication is also a key factor in this process because it infuses all facets of a healthcare institution, ranging from the provision of healthcare to enhanced performance leading to a better quality of care (General Joint Commission, n.d., p.3).

Sentinel events is a major issue that not only threaten the reputation of healthcare organizations but can also lead to loss of lives or permanent damage to patients in a medical setting. As noted earlier, the lack of effective communication among medical staff members has been identified as one of the causative factors of incidents of sentinel events. However, there have been a number of remedial measures initiated to mitigate recurrence of sentinel event. For example, the adoption of Priority Focus Areas guideline will enable healthcare organizations to identify and rectify circumstances that contribute to the emergence of sentinel events. Training programs on basic communication skills will also enhance healthcare delivery system by fostering staff communication and collaboration, multidisciplinary teamwork and information dissemination that will improve the quality of care delivery and functioning.

References

Daniel, M & Rosenstein, A. H. (2005). Professional Communication and Team Collaboration. Web.

General Joint Commission. (n.d.). Priority Focus. Priority Focus Process Report Summary. (1) 1

Manohar, R. (2008). Quality Operating Process. Web.

Sentinel event. (n.d). Nightingale Community Hospital. Sentinel Event Report. (1) 1

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Healthcare: Root Cause Analysis

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