Accreditation Audit AFT 2 Task 2 Sentinel Event 1
Task 2 Sentinel Event
Western Governors University
Accreditation Audit AFT 2
Accreditation Audit AFT 2 Task 2 Sentinel Event 2
A1. Sentinel Event
A three-year-old patient was admitted to the Ambulatory Surgical Unit (ASU) on the
Nightingale Community Hospital campus for bilateral myringotomies. The minor patient was
accompanied by her mother. After the patient was registered, the preoperative nurse (herein
referred to as E1) called the patient and her mother to the preoperative area. The patient would
then be prepared for surgery. E1 informed the patient’s mother that the surgery would take 45
minutes, and that the patient would remain in recovery for one hour. The mother informed E1
that she needed to leave the hospital to complete an errand with the patient’s older sibling. The
mother asked E1 to call her cell phone if the patient was ready for discharge before the estimated
time that E1 provided.
The patient's mother returned to the ASU two and a half hours after the patient was
prepared for surgery. Then, the mother learned her daughter was discharged 30 minutes before
, arriving at the hospital after completing her errand. The mother was distraught by this news,
hospital security was engaged, and a Code Pink was called throughout the ASU. An ASU
security officer (herein referred to as E2) interviewed the mother. During the interview, it was
revealed that the patient’s parents are divorced; the mother has full custody of the patient and
their siblings. Law enforcement located the patient with her father 30 minutes after the Code
Pink was called. The father picked up the patient and took her to his home to wait for the mother.
Charges were not filed against the father. The CEO of Nightingale Community Hospital (herein
referred to as E3) spoke with the mother. The CEO is committed to analyzing this incident and
revising the current process to ensure that it does not happen to another minor patient.
Task 2 Sentinel Event
Western Governors University
Accreditation Audit AFT 2
Accreditation Audit AFT 2 Task 2 Sentinel Event 2
A1. Sentinel Event
A three-year-old patient was admitted to the Ambulatory Surgical Unit (ASU) on the
Nightingale Community Hospital campus for bilateral myringotomies. The minor patient was
accompanied by her mother. After the patient was registered, the preoperative nurse (herein
referred to as E1) called the patient and her mother to the preoperative area. The patient would
then be prepared for surgery. E1 informed the patient’s mother that the surgery would take 45
minutes, and that the patient would remain in recovery for one hour. The mother informed E1
that she needed to leave the hospital to complete an errand with the patient’s older sibling. The
mother asked E1 to call her cell phone if the patient was ready for discharge before the estimated
time that E1 provided.
The patient's mother returned to the ASU two and a half hours after the patient was
prepared for surgery. Then, the mother learned her daughter was discharged 30 minutes before
, arriving at the hospital after completing her errand. The mother was distraught by this news,
hospital security was engaged, and a Code Pink was called throughout the ASU. An ASU
security officer (herein referred to as E2) interviewed the mother. During the interview, it was
revealed that the patient’s parents are divorced; the mother has full custody of the patient and
their siblings. Law enforcement located the patient with her father 30 minutes after the Code
Pink was called. The father picked up the patient and took her to his home to wait for the mother.
Charges were not filed against the father. The CEO of Nightingale Community Hospital (herein
referred to as E3) spoke with the mother. The CEO is committed to analyzing this incident and
revising the current process to ensure that it does not happen to another minor patient.
