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Code Pink incident at hospital....

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Accreditation Audit AFT2

Accreditation Audit AFT2 Task 2 WGU

A1) Sentinel Event

Accreditation Audit AFT2 A female child, Tina Gerhardt who is 3 years old, presented at admissions with her mother. Tina was scheduled to have insertion of ear tubes in the ambulatory surgery unit. Tina was registered and then Tina and her mother went with the pre-op nurse to the pre-op area and was prepped for surgery. During this time, the mother was advised that the surgery would take approximately 45 minutes and that Tina would need to spend about an hour in recovery. The mother stated to the pre-op nurse she had something to do for her older child, so she would be leaving the hospital. The mother wrote down her contact number and asked the pre-op nurse to have someone contact her, if she wasn’t back, if her daughter got out of surgery earlier than anticipated. The mother returned approximately 2.5 hours later, which was later than the estimated surgery time. Upon arrival the mother was informed that her daughter, Tina, had already been discharged approximately 30 minutes ago. Tina’s mother became tremendously upset. At this point Security was called and quickly issued a “Code Pink” which is an alert for a hospital-wide abduction. As well, the local law enforcement was contacted and apprised of the situation. The security officer came to investigate the incident and question the mother. At this point, she let him know about her circumstances with Tina’s father and that she was the parent who had full custody of the children. The outcome of this incident is Tina was located within 30 minutes of being reported missing. She has been picked up by her father after her surgery when the mother had not yet returned. Tina was found at her father’s house where they were waiting for her mother to return and no

Accreditation Audit AFT2 charges were filed against Tina’s father. As well, our CEO assured Tina’s mother we would examine this incident to prevent anything like this from happening in the future. A2) Personnel During the investigation of the incident, 8 personnel were identified to interview. Those interviewed are listed below: Anna Liu-Dilarno, Chief Nursing Officer, not present at time of incident: As the Chief Nursing Officer at Nightingale Community Hospital Anna’s role is to oversee all nursing staff at the hospital. A CNO is an executive role and “is the nursing leader who oversees the implementation of patient care within an organization. Their goal is to maintain patient safety and improve patient outcomes. A broad knowledge base of the healthcare environment and the ability to visualize how each part of the organization works is valuable to improve clinical practice, incorporate policies and ensure adherence to required regulations” (“What Does a CNO Do?”, 2014). Though Anna was not physically present during the incident, she holds a great amount of the responsibility for the actions of her nursing staff. Greta Doppke, Pre-Op Nurse, present during incident: As a pre-op nurse, Greta’s “primary responsibility is to provide information and emotional support for patients and their family members, to ensure that all preoperative data have been accumulated, and to maintain patients' baseline hemodynamic statuses” (Dunn, 1997). Greta did perform her job duties as a pre-op nurse, however her communication and follow through were lacking in this case.

Accreditation Audit AFT2 Rosemary Fry, OR Nurse, present during incident: As the OR Nurse, Rosemary’s responsibilities include monitoring patients during procedures, assisting patients with pain management and/or helping them after the surgery, and to timely complete all physician’s orders. Communication is another key responsibility for the OR nurse, whether it is before, during, or after surgery as well as clear communication with the patient. Rosemary completed her duties in regards to Tina’s care and because she was unaware of the mother’s request, was not able to help coordinate the communication necessary. Jon Peters, Recovery Nurse, present during incident: The recovery nurse in a hospital is responsible for monitoring and caring for patients in post-op. They are also responsible for any communication, education or homecare instructions after the patient’s surgery. As well, they are there to answer questions, calm fears, and ensure there are no post-operative complications right after surgery. Jon preformed his job duties as recovery nurse and followed protocol for Tina’s post-op recovery. He stayed with her, attempted to reach Tina’s mother by paging her and calling out in the waiting room but was not able to actually reach the mother. He then handed Tina off, without reaching the mother, to the discharge nurse. Kim Johnson, Discharge Nurse, present during incident: As the discharge nurse Kim is responsible for giving patient instructions, reviewing medications with the patient or guardian. Ideally this role should also be involved in any improvements in the discharge process as its goal is “to provide a more effective discharge process for patients and a supportive environment for nurses” (University of Texas M.D., 2008). Kim did the basics

Accreditation Audit AFT2 of the job which was first waiting an additional 30 minutes for the mother to return, then when she had not Kim gave the discharge instructions to the father. However, a breakdown occurred because Kim first allowed the father to come back into the post-op room, then relied on the patient’s reaction to the father for allowing the discharge to another person other than the mother. Tim Blakely, Security, not present during incident but alerted right after: The role of the hospital security guard is multi-faceted. The security guard’s main duty it to protect the people in the hospital, protect the property, and to respond swiftly to any security emergencies that arise. When notified, Tim did respond immediately and quickly went to the Ambulatory Surgery Unit to conduct an interview with the nurse who alerted the hospital to the urgent situation and also interviewed the mother. This is when he found out that the mother and father were divorced and the mother had custody of the children. As well, Tim did notify local law enforcement and shared the pertinent information which resulted in locating the child. Carols Munoz, Surgeon, present during surgery only: The surgeon is the provider who performs any surgical procedure for the patients within the ambulatory surgery unit. They are responsible for the outcomes of the surgery and the general care for the patient during the procedure. Dr. Munoz successfully performed the surgery to put tubes in Tina’s ears, however, his office failed to provide the necessary paperwork outlining the child’s home situation. This would have been vital information to share with the ASU. Katie Jessup, Registrar, present during incident:

Accreditation Audit AFT2 Katie’s responsibility as a Registrar is to take information from the patient or guardian and enter that information into the electronic medical records. As a Registrar, it is important to be a detailed as possible in order to have all pertinent information recorded. Also, as a Registrar, Katie was the first point of contact for Tina and her mother. The information that was missing, guardianship of Tina, wasn’t required of Katie to obtain. However, this was pertinent information that should have been coordinated between the Surgeon’s office and the hospital’s Registrar. A2) Personnel Issues There are two major issues that have negatively impacted how the hospital handled care of the child, Tina. The first issue is the lack of accountability and responsibility from personnel, specifically coming from the nursing department, under management of the Chief Nursing Officer. Policies may have been in place however they were not clearly outlined and need more definition and follow through from the nursing staff. All along the way, each individual nurse did not perform a proper handoff of the patient to include information necessary to keep the child safe and well cared for. Starting with the pre-op nurse, who did write the mother’s information down, but failed to do anything with that information was the first gap in the process. Each separate nurse acted as such, with separate interests of their specific role and not as a team providing care for a patient. Because the CNO is in charge, she should be the one to take responsibility and accountability for this incident. The CNO needs to ensure first, that detailed and appropriate policies are in place, and then are properly followed by each member of the nursing staff. The last gap in the process was the discharge nurse, who, without a proper release, allowed the child to go home with a parent that was not present during admission.

Accreditation Audit AFT2 Each of these nursing team members lacked an capacity to be accountable to each other in their communication, which also involved documentation, and to have an ability to work cohesively together. The second issue is the lack of security measures related to the ASU. The staff were either not aware or did not follow safety protocol when the admitting parent isn’t present after the surgery of a child. More specifically, the discharge nurse, without consulting security on proper protocol, allowed the child to go home with someone who had not been properly identified. If rigid policies were in place, trained on, and followed, there would have been a different outcome. After the incident, the security officer clearly outlined the deficiencies that exist which included the need for a standard operating procedure, more policies in place that are consistent with surrounding area hospitals, abduction training drills need to be held, and better overall security within the hospital such as arm bands and lock down procedures. If more security measures had been in place, even with the disfunction of the nursing department, the incident would have been prevented. A3a) Improve Interactions For the first area identified, the accountability and responsibility of the nursing staff, the CNO needs to work directly with that team to improve interactions among them, while also working on clearly defined policies and roles for each member. The CNO should also hold regular meetings with the nursing staff to ensure understanding and compliance of all additional polices along with how each role interacts with the other nursing role. In addition, the policies should include better verification and information input into the system, as well as a proper

Accreditation Audit AFT2 handoff document to each nurse who interacts with the patient. Putting these systems in place will help lessen any potential gaps that occur during the transfer of care of a patient. For the second area identified, the lack of security measures, a more robust and welldefined security protocol should be instituted. Incidents, such as the one with the child Tina, should be taken more seriously by everyone. “Violence in hospitals and health care facilities is a serious issue, but proper training and security planning can help to reduce the number and potential for incidents” (Ferenc, 2016). To address the issue, better policies need to be outlined within the security department. Specifically, a better policy surrounding patient safety such as checking in and out visitors plus better identification and documentation for parents or guardians waiting through the surgery of a child. At minimum, each underage patient should have a document in their records stating who can be in the waiting area and who will be responsible for picking up the child at discharge. As the security guard in the incident stated, there needs to be a system such as arm bands in place. These arm bands would match the child’s identification bracelet and only the matching adult would be allowed to pick up the child. If it was well documented in the records that a second adult would be allowed, then that adult should also have a matching arm band. In addition, all staff at the hospital should be trained and periodic drills be performed on abduction protocol. This way, if a true abduction were to occur, the staff would be well prepared to handle such a situation. A4) Quality Improvement In order to determine the root cause issue surrounding this incident a quality improvement tool should be utilized. There are many factors to consider, especially with several

Accreditation Audit AFT2 possible gaps which were identified in this situation. The tool best suited for finding the root cause would be a fishbone diagram which is also called a cause and effect diagram. Fishbone diagrams are often used in many quality improvement measures as it helps to locate imperfections or actual failures in the process. “The fishbone diagram is especially useful during the problem definition segment of brainstorming sessions, where it helps individuals and teams to deconstruct problems and challenges. By dissecting the problem and recording its possible causes in writing, this process can often illuminate potential solutions” (Frey, 2013). Because this incident could have been a true life or death situation, the hospital needs to identify quickly the failure in the process and what role the staff played in the breakdown. B1) Risk Management Program To ensure this type of incident never happens again, a risk management program needs to be put into place. A committee should be formed to review and analyze the root cause and/or causes of why this event happened. The committee needs to consist of several areas of the hospital to include the Hospital Administrator, CNO, Director of Security, Admissions Manager, VP of Human Resources, Director of Legal and Compliance Department and Director of IT. Together, once the root causes are identified, will develop policy and protocol surrounding these gaps. Such changes will include: 

Additional documents necessary for admission to include pertinent information from the referring surgeon as to the patient’s emergency contact information and legal custody if the patient is underage. As well, specific information will be collected and recorded in

Accreditation Audit AFT2 the electronic record as to which parent/guardian admitted the child and who is to pick up the patient after the surgery is completed. 

Forms will be developed and trained on regarding the “handoff” of every patient from admitting to discharge. This form will be an electronic document which will time stamp the user who handed off as well as the user accepting the handoff of the patient. Retraining the nursing staff on the use of the handoff will require the CNO to firmly require, train and implement and oversee the new protocol. As well, any additional information that needs addressed during the handoff will be put into the electronic chart by the nurse or staff member receiving the information.

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New safety protocols will be put into place and trained on regularly. These new safety protocols include matching arm or wrist bands which link the patient to the responsible party at discharge who is picking up the patient. As well, patient visitor information will be recorded and placed in the patient’s electronic chart. This will include any visitor who was present at admissions, waiting during surgery, and at picking plus any additional potential visitors the parent/guardian deems possible during the admission process. The hospital will also conduct quarterly safety drills which will include abduction attempts, violent patients, and violent visitors. The drill will run through what each staff member present should do in such an occurrence.

Each head of the department involved in these changes will be required to lead and conduct training on all changes outlined above. As well, in collaboration, Human Resources and Compliance will ensure these trainings are documented and take place along with ongoing metrics to guarantee compliance on all new measures. The IT department will develop and run

Accreditation Audit AFT2 reports based on the electronic health records documentation of the use of the new admissions forms, the use of the new handoff electronic document and the use of patient/guardian identification bands. Lack of adherence to these new protocols will involve disciplinary measures and if severe enough, could lead to termination of the staff member. B1a) Resources The main resources necessary to achieve these changes will be time, funding, and buy-in from those needing to implement the changes. Time is necessary to develop the written protocol and confirm that it is compliant with all legal standards required for a hospital system. The funding is necessary as it will take additional dollars to rewrite admissions documents, develop and prepare the electronic handoff document, as well as both time and funding to provide training and regular drills for all staff. The Hospital Administrator is vital to the role out of the changes and is responsible for getting the buy-in from all executives and board members. In conjunction with the Hospital Administrator, the key individual who will oversee compliance with the biggest staffing department is the Chief Nursing Officer. As identified earlier, the nursing group is the most accountable for the failure in this incident and as such, it is important that the CNO take full responsibility and enforce these new protocols.

Accreditation Audit AFT2

References

Dunn, D. (1997). Responsibilities of the Preoperative Holding Area Nurse. National Center for Biotechnology Information Ferenc, Jeff (2016). Establishing a hospital security plan that works. ASHE Health Facilities Management Frey, Chuck (2013). The fishbone diagram: An essential visual tool for problem solving. The Mind Mapping Software blog University of Texas M.D. (2008). Discharge Nurse Position Description. Robert Wood Johnson Foundation “What Does a CNO Do?” (2014). Lamar University, Member of The Texas State University System

Accreditation Audit AFT2...