NIGHTINGALE COMMUNITY
HOSPITAL.
RCA (ROOT CAUSE ANALYSIS)
FOR THE SENTINEL EVENT REPORT
HAPPENED ON MAY 14,
THURSDAY AT 9:00 AM.
1. SENTINEL EVENT DESCRIPTION.
The pre-op nurse told the mother that once Tina (The patient), a 3 years old child, went to the OR, her surgery would take about 45 minutes and then she would go to recovery and she would be there at least one hour. The mother told the nurse that once Tina went to the OR, she needed to run a quick errand involving an older sibling and would return in time to pick her up once she got out of recovery. The mother gave the pre-op nurse her cell phone number
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She never imagined that the father wouldn't have custody or whatever.
A few minutes later the mother came, and she was very upset and she apologized to her for the mistake that committed.
5. SECURITY OFFICER.
At 9:00AM, he got a call, telling him about a potential child abduction, immediately he responded to the ambulatory surgical unit, discharge are and interview the nurse, which it told him that a minor patient has been missing for approximately 25 minutes, he was upset that he wasn't called sooner.
6. REGISTRAR.
When the mother and the patient came to her desk, she took care of entering the information need it, in the registration section of the electronic medical record form, asked for the insurance situation and gave the mother the admission and treatment form.
She didn't ask for any other identification form, because it isn't part of the registration process, specially about any custodial information, because also it isn't part of the registration process. She just did exactly was she was tough to do and what she has been doing for a long time.
7. SURGEON.
Most likely he performed the surgery. He is the number one doctor in pediatric outpatient surgery at Nightingale Community Hospital.
8. CHIEF NURSING OFFICER.
She wasn't actually involved in the sentinel event, but she the person responsible for all the nurses at Nightingale Community Hospital. She will like to know what happened and determined a good
There was no hand off of the cell phone number the mother provided to the pre-op nurse. As there is no documented area on any of the forms for this information, the process relies on verbal handoff and memory of the nurse. There was no alternate phone number available for the nurse to contact the mother or other designee.
Appointment/Registration - This determines whether an individual is an established or new patient; if the patient is new, then insurance information is obtained and verified to make sure that the patient qualifies to receive services from the provider.
After the recovery process was completed, the patient was placed in the care of the discharge nurse. She was given a report and was aware that the mother had not showed up to collect her child and several overhead pagers had been performed. While the interview was taking place the nurse stated that she was unsure how to proceed, with the mother not being located, the nurse stated that she was relieved when she was informed that the patient father was there, the discharge nurse stated that the
On 6/11/15 at 2:00 pm, I called Dr. McClain at his listed home number to confirm he was still in the area and to inquire if he would be available for an interview at some point. Dr. McClain began explaining that to his knowledge all of the complaints had been “kicked out” except for one case involving an ileostomy reversal. That complaint resulted from him being told not to have contact with patients since he was under investigation. The patient was upset because they could no longer see him, McClain stated.
Under the instruction of the patient’s mother, the pre-op nurse was to contact her by cell phone if times for release had changed.
On 5/13/2015 I met with Dr. Navato at Centerpoint Medical Center. Dr. Navato was familiar with the complaint as she had submitted a narrative response to the BHA in February of 2015. The allegation was that Dr. Navato did not honor a (Do Not Resuscitate) order.
Patient fills out and signs new patient registration forms. Copies of I.D. and insurance cards are made.Create encounter form and new patient chart.
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She stated she did not have the patient and the only contact was with the nurse was the phone call.
Traditionally patient registration involves mailing registration forms to patients prior to their appointments and requesting them to fill it out before they come for their doctor’s visit or asking them to arrive early in order to complete the registration process. An online registration method can save time for administrative team by expediting the entire process while providing better services. Less time dealing with these activities can control the cost of those activities to accomplish patient registration process.
You first begin with registering your patient, here, you collect important and correct information, demographics, such as patients age, address and insurance information. It is crucial that the correct information is collected because eligibility can be affected. A study done in 2003, by the Health Insurance Association of America, reported that
Henri Ford who was elected president of American Pediatric Surgical Association, which is the most rare and prestigious milestone for a surgeon
When the surgery was done the doctor came out and said he wanted to talk, The doctor
Add Registration. The health official evaluates if the patient is already registered in their paper based. If the patient is new, registration form is filled out the patient