Root Cause Analysis Due to Sentinel Event Essay

7032 Words Aug 9th, 2011 29 Pages
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
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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

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