Root Cause Analysis Due to Sentinel Event
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 allowed the father, against the mother’s wishes, to check Tina out of the hospital. The hospital staff, had attempted to contact the mother multiple times prior to the check-out or release. According to the call logs, six attempts to contact the mother were made by the post-op nurse in the 45 minutes the mother was delayed in arriving.
According to the admitting paperwork the insurance for Tina’s day surgery was under the father’s name and policy. The hospital followed standard admitting and release procedures, but was surprised when Tina’s mother did not show or answer her phone. Tina’s father did not indicate suspicion or nervousness, he provided the proper documentation and verification of identity. The daughter confirmed that the gentleman was her father and it was obvious they were comfortable with each other.
When Tina’s mother arrived, she was extremely distraught, the hospital contacted security immediately, and a “Code Pink” (hospital-wide child abduction alert) was activated. The Local law enforcement was also contacted by hospital security and provided the police with the fathers contact information and address.
As the hospital security officer interviewed the mother, she shared with him that she and Tina’s father
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 allowed the father, against the mother’s wishes, to check Tina out of the hospital. The hospital staff, had attempted to contact the mother multiple times prior to the check-out or release. According to the call logs, six attempts to contact the mother were made by the post-op nurse in the 45 minutes the mother was delayed in arriving.
According to the admitting paperwork the insurance for Tina’s day surgery was under the father’s name and policy. The hospital followed standard admitting and release procedures, but was surprised when Tina’s mother did not show or answer her phone. Tina’s father did not indicate suspicion or nervousness, he provided the proper documentation and verification of identity. The daughter confirmed that the gentleman was her father and it was obvious they were comfortable with each other.
When Tina’s mother arrived, she was extremely distraught, the hospital contacted security immediately, and a “Code Pink” (hospital-wide child abduction alert) was activated. The Local law enforcement was also contacted by hospital security and provided the police with the fathers contact information and address.
As the hospital security officer interviewed the mother, she shared with him that she and Tina’s father