Nightingale Community Hospital Case Study

The Nightingale Community Hospital is investigating a recent sentinel event involving the potential abduction of a three-year-old child. The Joint Commission (2017) considers a sentinel event as the risk of or the occurrence of an unexpected patient safety event which involves death, a serious physical or psychological injury. Moreover, an event is also considered sentinel if it involves the abduction of any person receiving care, treatment, or services.

On the morning of September 14, a three-year-old child was admitted to same day surgery for a surgical procedure. The usual registration process was performed to complete the required documentation and necessary payment authorization forms. After the registration process, the patient

Afterwards, the patient was transferred to the Recovery area to be monitored while waking from the anesthesia. The recovery nurse attempted to locate the patient’s mother by calling the waiting room and paging but received no response. Once recovered from the anesthesia and fully awake, the patient was transferred to the post-op area for the discharge process. The recovery nurse informed the discharge nurse that he was unable to locate the child’s mother in the waiting area or by page. The discharge nurse was unsure what to do since no one could locate the patient’s mother. A short time later, security notified the discharge nurse that the child’s father was in the main reception area. The father was allowed in the discharge area where the child recognized and acknowledged her him. After waiting a while longer for the mother, the father offered to take the patient home. Discharge instructions were given to the father and the patient was released to his care. The mother returned approximately 30 minutes later and became very upset when she was notified that the patient had been discharged earlier to her father’s care. The discharge nurse notified