Accreditation Audit (AFT2) Task 2
Root Cause Analysis

Nightingale Community Hospital is a non-profit 180-bed acute care facility that provides compassionate cost-effective leadership in quality health services related to treatment and prevention, which encompasses several service lines. Their vision is to be the hospital of choice for patients, employees, physicians, volunteers and the community which they serve. Their mission is to create a healing environment, with a passionate commitment to healthcare excellence. There are four core values that they pledge to the community and expect of themselves:
Safety
We believe that excellence begins with providing a safe environment. We put our patients first as we seek to exceed the expectations of our customers with superior service, outstanding clinical care and unsurpassed responsiveness.
Community
We reach beyond our walls to engage in partnerships that improve the education and healthcare needs of our community. We invest in the community by continually improving services and broadening our spectrum of care.
Teamwork
We collaborate with others for the benefit of all. We acknowledge differences among people and recognize strength of diversity.
Accountability
We provide cost-effective, quality services; we foster the financial strength, stability and growth of Nightingale's; and we support individual initiative and innovation.

Sentinel Event

On September 14, 2014 at 12:30 PM there was a sentinel event at Nightingale Community Hospital. A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome (JCAHO 2014). The event involved a 3 year old minor that was in for ambulatory surgery. Admission to the treatment facility was through the custodial mother. At the conclusion of her hospital stay the minor child was discharge to a non-custodial parent. During the pre-operative work up the mother mentioned to the pre-op nurse that she had a quick errand to run with her older child and would return in time to pick her 3 year old. The pre-op nurse asked the mother for her contact information and wrote it down in her notebook. The mother instructed the nurse to contact her if she had not returned to the hospital before the surgery had completed. Details of the event were gathered through one on one interviews starting with registration. The registration clerk, was responsible for the registration of the minor child, openly admits that the mother was the person to provide the registration details for the child. During the interview process the clerk cited that asking if there is a custodial parent is not part of the admission forms or protocol. The pre-operative (Pre-Op) nurse escorted the minor and her mother to the pre-operative area; she administered pre-operative meds, completed the pre-operative nursing assessment, started the IV, documented the Medication Administration Report (MAR), had the mother sign the consent form, and provided the patient with a gown. The pre-op nurse admits that she took a note, on her note pad, that the mother would be outside of the facility and took her cellular number. However, she neglected to document this in any documentation that followed the patient through to discharge. Once all of the pre-operative tasks were completed the pre-op nurse took the minor to the Operating Room (OR) and handed her off to the OR nurse. The OR nurse takes the minor patient to the OR while the mother leaves the facility. There was no discussion between pre-operative nurse and the operating room nurse about the mother’s absence during the surgical procedure or how to contact her should an emergency arise during the surgery or if she was not in the waiting area when the minor child was ready to be discharge. Once the minor child