(Solution) Accreditation AFT 2 KCM Task 2

Description of the Sentinel Event
A sentinel event occurred at Nightingale Community Hospital when a three-year-old patient, Tina Gerhardt, was discharged to her non-custodial father without authorization, leading to a serious breach of patient safety and security. Tina had been admitted to the Ambulatory Surgery Unit (ASU) for a scheduled bilateral myringotomy, a standard pediatric surgical procedure involving the insertion of ear tubes. Before the procedure, her mother informed the pre-operative nurse that she needed to leave the hospital to attend to an older sibling briefly but would return in time for Tina’s discharge. She provided her cell phone number and requested to be contacted if Tina was ready for discharge earlier than expected. However, a critical breakdown in communication and adherence to hospital discharge protocols resulted in Tina being released to her father, who did not have legal custody. This unauthorized discharge not only caused emotional distress to the mother but also triggered a serious security incident within the hospital.
Approximately two and a half hours after dropping off her daughter, Tina’s mother returned to the hospital to find that Tina had already been discharged 30 minutes earlier. When she was informed that her daughter had been released, she became highly distraught, realizing that the hospital had failed to follow proper identification and discharge procedures. She immediately raised concerns, prompting hospital security to intervene. Recognizing the severity of the situation, security personnel initiated a “Code Pink,” a hospital-wide child abduction alert, signaling all staff to assist in locating the missing child. In addition, local law enforcement was contacted to aid in the search and ensure Tina’s safety. The hospital’s failure to properly verify the identity and legal custody status of the individual collecting Tina represented a significant lapse in patient safety measures.
Local law enforcement officers quickly located Tina within 30 minutes at her father’s home, where he was waiting for her mother’s arrival. While no criminal charges were filed against the father, as he had not abducted the child by force, the incident exposed a major security vulnerability within the hospital’s discharge process. The hospital staff had neglected to confirm parental custody arrangements before releasing Tina, leading to an unauthorized discharge that could have had more serious consequences. This incident highlighted deficiencies in staff training regarding patient identification, discharge protocols, and custody verification. Furthermore, it underscored the need for clear policies on handling minor patients to prevent similar security breaches in the future.
Following the incident, the CEO of Nightingale Community Hospital assured Tina’s mother that a thorough root cause analysis would be conducted to investigate the failures that led to this sentinel event. The hospital committed to identifying weaknesses in its policies and implementing corrective measures to prevent future occurrences.