L.

Kelly
237800
AFT Task 2

A. Summary of a Root Cause Analysis

1.) Sentinel Event

 Thursday, September 14th at 12:30pm, a three year old female (Patient GERHARDT,

Tina) was brought into the Ambulatory Surgery Unit (ASU) at Nightingale Community

Hospital for ambulatory surgery for bilateral myringotomies. Following Mother

registering patient, pre-op nurse called them to the pre-op area to be prepped for surgery.

The pre-op nurse informed the child’s mother that once patient went into the OR, her

surgery would be approximately 45 minutes with an estimated 1 hour in recovery.

 Patient’s mother informed the pre-op nurse she would be leaving the hospital as soon as

her daughter went into the Operating Room but would be back by the time she was out of

recovery to pick her up. The mother gave the pre-op nurse her cell phone number and

requested that she be contacted if her daughter was to get out of surgery earlier than

expected.

 Approximately 2 ½ hours later, the patient’s mother returned to the hospital. Her

daughter (patient Gerhardt, Tina) had been discharged 30 minutes prior to her arrival.

The mother was visibly distraught.

 In response, Security activated “Code Pink” to alert the hospital community of an

abduction alert. Local law enforcement was then contacted by Security.

 Security interviewed the mother. She shared that she is divorced from the patient’s father.

Mother has full custody of patient and patient’s siblings.

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  Patient was located in the care of her father by local law enforcement within 30 minutes

of mother’s arrival. The father had taken the patient to his home to wait for the mother’s

arrival.

 No charges were filed against the father.

 CEO of Nightingale Community Hospital told mother there would be an analysis of the

incident with processes put into place to prevent a similar event from being repeated.

2.) Present personnel during sentinel event

 Chief Officer- responsible for nursing staff in the hospital.

Role in Sentinel Event: Was not present at the sentinel event but recognized that there is

problems with communication among the nursing staff. She also expressed that there is problems

ensuring that the nurses have entered information into the system.

 Registrar- key patient service support; First point of contact. Responsible for entering

patient demographics, insurance information, and having Admission/Treatment forms signed.

Role in Sentinel Event: Followed protocol for registration by entering in pertinent information

into the electronic medical records (EMR), requested copy of insurance card and had proper

admission form signed and filed.

Registrar did not verify identification of patient or mother. Custodial care was not questioned.

Neither pertinent pieces of information are included in the routine registration/admission forms

nor are they prompted within the EMR.

 Pre-Op Nurse- Responsible for preparing patient for surgery. Completes pre-operative

nursing assessment, starts intravenous fluids, administers pre-op medications, documentation

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 of preparations into the EMR, and has the Informed Consent form signed by patient or

guardian.

Role in Sentinel Event: Followed protocol and policy for completing pre-operative nursing

assessment and documentation. Neglected to further document into EMR mother’s cell phone

number and directions for pick-up. Legal custody and guardianship identification were not

addressed as this is not prompted on the pre-op assessment or EMR assessment frame.

 OR Nurse- Responsible for receiving patient for surgery in the operating room, cares for

patient before, during and after surgery, works along-side the surgical team, and serves as a

liaison between surgical team and the patient’s family.

Role in Sentinel Event: As per the Pre-Op Nurse, received patient at point of operating room.

Conveyed surgery report to Recovery Nurse.

 Recovery Nurse- Responsible for providing patient post-anesthesia care, takes patient’s to

ambulatory surgical unit’s post-operative area for discharge.

Role in Sentinel Event: Provided patient with post-anesthesia care. Received surgery report from

OR Nurse. Paged mother in waiting area once patient was awake. Mother was not present in

waiting area. Transported patient to the Post-Operative Area for discharge once patient was fully

recovered.

 Discharge Nurse- Responsible for establishing patient referrals with health care services,

gives written conveys doctor’s orders for after care, medications, and treatment, then

documents the discharge planning process.

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Role in Sentinel Event: Received patient from Recovery. Recovery Nurse communicated that

patient’s mother could not be located in the waiting area. Received call from Security stating that

patient’s father was at main reception. Allowed Father into Post-Operative area for discharge to

see daughter. Discharge Nurse felt it was identification when the patient recognized the man as

her father. Father offered to take patient home after waiting 30 minutes for the mother. Discharge

instructions were given and patient went home with father.

 Security- Responsible for performing infant abduction drills; activating Codes that involve

abductions and security of patients.

Role in Sentinel Event: Responded to potential child abduction call from the Ambulatory Surgery

Unit’s discharge area. Interviewed the Discharge Nurse. She stated patient had been missing for

approximately 25 minutes. Activated a “Code Pink” and called the local law enforcement.

 Surgeon- Responsible for performing pediatric ENT surgery, forwarding pertinent patient

office notes and admission orders to proper departments at Nightingale Community Hospital,

and signing/dating all documentations made within the patient EMR.

Role in Sentinel Event: Surgeon’s patient office notes were not sent to hospital that stated the

patient’s custodial parent.

3.) Personnel Issues 3a.) Improve Interactions

Organizational barriers were impeding effective interaction among personnel who were

directly involved in the Sentinel Event. Confusion and obstructions occurred in the

communication process as a direct result from the poor definition of the staff’s roles within the

hospital’s system. From the first point of patient contact, to the discharging of the patient with

the wrong parent, each staff member believed that the task of identifying guardianship and

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properly documenting start to finish notes on patients were the responsibility of someone else.

Because the organization lacked policy, procedure, and a written protocol, staff simply set aside

the responsibility of patient identification and safety. Then, individual staff members assumed

that someone else would perform the necessary steps rather than ensuring that someone accepted

ownership. In order to improve this communication barrier, a specific protocol needs to be

followed along with extensive training and clarification of personal roles and responsibilities.

Further, a change in the organization’s culture to embrace a team player atmosphere would

encourage personnel to make each step of patient security a personal responsibility.

Organizational barriers directly attributed to poor operational skills caused by the lack of

procedures that would have helped to define and direct a process for an appropriate line of

communication. The unfortunate result was the absence of understanding what other departments

operations were responsible for. The involved staff clearly were without a level of appreciation

and comprehension of individual personnel’s roles. Thus, unrealistic demands were placed on

each other. In order to improve and avoid the confusion and misinterpretation, employees should

be trained in awareness in regards to the functions of other departments and the responsibilities

of external health care providers. Personnel should place ownership to following up on minor

patients guardianship, pick-up information, and identification of patient-guardian relationship.

Hospital staff must have an appreciation and understanding of what roles each department of the

hospital plays within the process in order to effectively communicate with one another.

Moreover, an inappropriate communication tool was used by a staff member. The recording

of key information for patient care and safety was documented inside a caregivers pocket

notebook. A selection of the best available communication tool to record a message is an

essential component of excellent, effective interaction among personnel. In the given Sentinel

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Event, it would have required more than one communication tool to deliver the correct level of

urgency and importance for the parent’s message. To improve the involved staff’s interaction,

the caregiver should have communicated face-to-face to another co-worker on that shift. Next,

the information should be documented into the patients EMR. This duty should take top priority.

Then, the department receiving the patient should be called and the information given verbally to

follow-up on the updated documented EMR information. At this point of contact, security should

be advised to the name and identification of the minor’s legal guardian along with the pertinent

information for a secure pick-up and discharge. Each department is an integral link to effective

interaction and consequently superior patient care and safety.

4.) Quality Improvement Tool

Because of their ability to visually lay out the sequence of events that lead to a Sentinel

Event, Flow charts followed by a Cause-and-Effect Diagram are excellent quality improvement

tools to use to conduct a root cause analysis. Flow charts boast the capacity to expose deficits

and obstacles in the process that might be preventing a smooth course of action. Then, using the

steps from the Flow Chart, the Cause-and-Effect diagram can be created to categorize the

discovered information to show relationships between the exposed causes and effects leading to

the Sentinel Event.

Flowcharts are chosen for root cause analysis because they are easily read by the lay-out of

standard symbols that point-out the beginning or end, the process being conducted, and the

decisions being made. Moreover, symbols help breakdown the events to many sub-processes

allowing for a clear analysis and discovery of unseen problems. Once the information is

transferred into a Cause-and-Effect Diagram, the brainstorming process can begin.

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 Cause-and-Effect Diagrams are chosen and used for root cause analysis because they

categorize the event’s causes into major branches connected to the central backbone line to the

diagram allowing for further brainstorming. When all the contributing factors are categorized a

fishbone structure develops and the facets of the problem can easily be seen. Typically, the main

issue is written at the beginning of the diagram with the branches identifying the causes related

to the major event.

Flow Charts and Cause-and-Effect diagrams were chosen for the root cause analysis because

of their quality to allow all those involved, the ability to see the event in the same way. Thus,

brainstorming and categorizing eliminates any cascading errors.

B.) 1.) Recommended Risk Management Program/Process Change

Action Plan
Root Cause(s)/Opportunity for Improvement(s):
a. Poor definitions of department/individual roles and responsibilities. Create an
environment that makes every step of patient care the obligation of all personnel.
b. Standardize an approach to “hand-off” communications, including an opportunity to
ask and respond to questions.
c. Absence of a well-defined Security process for pediatric patients. Including
a verification process for guardian identification

a.) Poor definitions of department/individual roles and responsibilities. Create an environment

that makes every step of patient care the obligation of all personnel.
Risk Reduction Strategy:
Staff Departmental Training. Employees will be given “Roles & Your Responsibility in and
Outside Your Department” booklets standardized for review and continual education.
Education and training using booklet as a tool for onboarding and current staff on individual
roles and responsibility.
Extend training to include overview of related department roles and responsibilities.
Additional in-service program to encourage teamwork and ownership of responsibilities.
Person(s) Responsible for Implementation:

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Director of Nurses
Human Resource Training Specialist
Target date of implementation:
6/25/2016
Location of implementation:
Extended Hospital Meeting Room
Completion date:
7/15/2016

Measures of Effectiveness/Performance Indicators:

Random sample of ninety (90) employee self-assessment surveys following all training systems
and education programs. Sample size was selected by using a computer generated list. Training
is ongoing and will be done annually.

b.) Standardize an approach to “hand-off” communications, including an opportunity to ask and

respond to questions.
Risk Reduction Strategy:
Implement a standardized content check-off list for Pediatric Hand-off communications.
Checklist will indicate the following questions
Is patient under the care of Department of Child and Family Services? If yes, obtain consent.
Is patient under care of CPS?
Parental custody and any issues related to parental custody must be indicated. Obtain
Copy of identification of custodial caretaker.
Standardized forms requiring review will be submitted to the Compliance Committee and the
Project Manager for updating and recommendations on a yearly basis.
Departmental-wide standardized process will include:
 Briefings among staff during shift changes,
 Patient room whiteboards that will list discharge plan, brief overview of key patient
information for all to see, along with daily goals, assigned nurse, and other pertinent notes
 Immediate documentation in patient medical record.
Person(s) Responsible for Implementation:
Compliance Team
Director of Nurses/Nursing Staff
Departmental Supervisors

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Compliance Committee
Project Manager
Target date of implementation:
6/30/2016
Location of implementation:
Surgical Departments
Admitting Department
Nurses Stations and Patient Rooms
Healthcare areas where key patient information is processed
Completion date: 7/15/2016
Measures of Effectiveness/Performance Indicators:
Director of Nurses will monitor and watch over implementation and competencies of licensed
staff using standardized forms and communication process. Audit tool will be used for staff
assessment in communication process. Compliance rate will be 100% at a monthly rate.
Project Manager will monitor training and watch over competencies for patient services staff,
admission staff, medical records staff, providers, nurses and licensed staff.
Standardized forms will be reviewed by the Compliance Committee annually. Compliance rate
will be no less than 95% for each year. Project Manager will conduct.
Patient surveys will be mailed 3 days after surgical discharge. Quantitative Questions will be
asked in regards to the use of white boards for visual communication and overall patient
satisfaction of communication. Compliance rate will be no less than 98% for each year.

c.) Absence of a well-defined Security process for pediatric/geriatric patients. Including a

verification process for guardian identification.
Risk Reduction Strategy:
Implement Security participation and Protocol for pediatric patients while in hospital care
Hospital departments will be assigned a color badge for staff to help in departmental
identification
Departments will be assigned colored scrubs to help in identification. Colors will be
changed on an annual basis
All personnel will make security their responsibility.
Security will have Code Pink training drills on a quarterly bases
Require at least one guardian/custodian to be present in hospital during surgery or procedures.
Implement identification bracelet system for pediatric patients that match guardian/custodial care
taker bracelet

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Patient/Guardian education program for abduction prevention
Video Surveillance system in all hallways, doorways, and nurses stations
Pediatric patients will be monitored while in a bassinet or pediatric bed/crib until the arrival of
designated guardian/custodial care into the treatment or authorized area.
Person(s) Responsible for Implementation:
Security Department Supervisor and Security Personnel
Patient Education Services Liaison
Director of Nurses
Admitting Staff and Supervisor

Target date of implementation:

6/30/2016
Location of implementation:
Hospital building, system-wide
Patient services and Admitting
Compliance Committee
All departments responsible in caring for pediatric patients
Completion date:
8/15/2016
Measures of Effectiveness/Performance Indicators:
Mock Abduction Drills will be conducted quarterly with recording of how far the mock abductor
can infiltrate restricted areas and leave building with mock pediatric patient. Documented results
will be analyzed using an audit tool. Data will be reviewed by Security Supervisor and
Compliance Committee for effectiveness and possible updating. Must reach 100% compliance
departmental-wide with full participation by hospital personnel.
Bracelet identification and matching will be monitored with a random sample of 50 inpatients.
Patients will be chosen by computer selection on a monthly basis.
Daily patient audit for guardian presence during entire duration of hospital stay. Assigned Nurses
will monitor and report in medical record. Data will be analyzed for effectiveness using random
computer sample selection of 50 patients. To be conducted weekly.
Video surveillance system will have QC testing for working order. Documentation of suspicious
individuals recorded will be reviewed on a daily basis to determine continual effectiveness.
Effectiveness must reach 100% yearly.
Pediatric patients being monitored in bassinet/crib/child bed will be audited by a random sample
of 50 patient medical records from surgery, radiology, and other related areas where separation

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from guardian occurs. Sample size will be randomly chosen by Compliance Committee. This
audit must be at 90% compliance rate.

All risk reduction measurement strategies will be evaluated and reported to Senior
Leadership within 3 months of completed and approved RCA and updated quarterly.

B. 1) a) Resources to support change:

Director of Nurses will assist in implementation and monitoring
Human Resource Training Specialist and Onboarding will assist in personnel training/education
Departmental Supervisors will assist in staff implementation and monitoring
Compliance Committee overview and review of Risk Management Program
Project Manager will Head the implementation and direction of the departments
Security Department Supervisor and Security Personnel will implement all security issues and
installation of new surveillance system
Patient Education Services Liaison
Admitting Staff and Supervisor will assist in training and implementation of program
Patient services and Admitting
Security Budget Financial Committee
-Contractor will be employed to help design an effective video surveillance lay-out,
design, and Security personnel training
The Joint Commission Handbook for resourcing and tools
Vendors for identification bracelet program for set-up, application, and training for key staff

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