RAFT Task 2
Sharon Walb
Western Governor's University

RAFT Task 2
A.1 Sentinel Event
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (http://www.jointcommission.org/sentinel_event).
Root Cause Analysis: Potential Child Abduction
Recently a three year old female was brought to Nightingale Hospital for an outpatient surgical procedure accompanied by her mother. They presented to the registrar who entered all information into the computer and copied insurance card, she did not obtain any parental photo identification or inquire about custody arrangements. Patient and her mother were taken to the pre-operative area to prepare for surgery and
Safety is the first core value of the organization and reports are posted for public viewing. Every unit level meeting addresses current safety issues or potential issues.
There was no literature search done to complete this analysis.

A.2 Personnel
Interviews were contacted with the staff that has been identified as being present during this sentinel event.
Registrar stated that she greeted the mother and child and entered all of the information into the computer and copied her insurance card. The duty of the registrar is to enter patient data into the system, including insurance information, have patient or parent review and sign HIPPA paperwork and handout the patient bill of rights.
Pre-op Nurse the role of the pre-op nurse is to complete a pre-op assessment, obtain consents for procedures, complete any education that the patient or parent needs, obtain contact information for parent/significant other in the event they need to be contacted during the procedure, reassure/educate patient and parents on the hospital routine, environment and procedure. The nurse we interviewed stated that she had completed the assessment and obtained consent. She also stated that she collected the mother’s contact information but placed it in her notebook.
OR nurse’s role is to make sure that the patient is comfortable, documentation within the OR is completed, assist with counts of surgical instruments and