Sentinel Events in Healthcare: Root Cause Analysis

When it comes to patient safety, sentinel events are a crucial concern for hospitals and their staff. According to the definition of the Joint Commission (2020), “a sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm” (para. 1). Consequently, preventing sentinel events is one of the primary duties of care providers. Sentinel events vary in terms of their nature but share a common characteristic of posing a severe risk to patients’ health and safety. When sentinel events do occur, it is essential to analyze them to determine the root causes and eliminate them to prevent similar occurrences in the future. The case in question involves a threat of child kidnapping. As noted by the Berker’s Hospital Review (2015), sentinel events of criminal nature were among the ten most common sentinel events in 2012-2014. Hence, evaluating the case and implementing corrective measures is necessary to prevent future risks to patient safety in the hospital.

Root Cause Analysis


The event described in the case occurred in the Ambulatory Surgery Unit (ASU) of the Nightingale Community Hospital. A three-year-old child was admitted for bilateral myringotomies. While she was in surgery, her mother had to leave the hospital, but she left her cell phone number with the pre-op nurse to stay in contact. When the mother returned two and a half hours later, she found that her child had already been discharged. The hospital security issued a Code Pink and contacted law enforcement. It was found that the child had been picked up by her father and was at home with him. No charges were filed against the father, but the hospital’s management requested an analysis and a corrective action plan to prevent similar events in the future.

The issue is that the patient’s mother should stay at the hospital to take her daughter after the surgery. Since she was not in the hospital, the patient’s father was contacted and took the child to his home. The mother was extremely distressed and told the police that they are divorced, while full custody was given to her over the girl. The pink code was canceled when the girl was found at her father’s home, but nobody notified the mother that the child was discharged.


The case involved eight members of hospital staff, and each of them was interviewed as part of the analysis. Anna Liu-Dilarno is the Chief Nursing Officer, so she was responsible for the actions of all nurses in the hospital. The pre-op nurse Greta Doppke had a responsibility to make all the necessary preparations for surgery, but she did not clarify legal custody or guardianship issues since they were not included in her assessment form. The OR nurse Rosemary Fry was responsible for supporting the surgeon during the surgery, collecting relevant patient information, and delivering the patient to recovery care after the surgery. Jon Peters, the recovery nurse, was responsible for post-anesthesia care and patient recovery until discharge.

The discharge nurse was Kim Johnson, and she had a responsibility to check the identity of the parent or guardian picking the child up, evaluate all the relevant documentation, and provide discharge instructions to the patient’s family. The security guard Tim Blakey was responsible for issuing a drill and contacting the local authorities, as well as for ensuring the security of the premises. The surgeon, Carlos Munoz, was accountable for providing surgery treatment to the patient, assessing her test results and other diagnostic information, and providing relevant notes to other interdisciplinary team members. Finally, Katie Jessup was the registrar involved in the case, and her duties involved filling in appropriate patient information, checking relevant documentation, and ensuring that the patient’s mother signed all the required forms.

Barriers to Effective Interaction

A detailed assessment of all the potential issues contributing to the event can be seen in Figure 1. Based on the outcomes of the interviews, there were three key problems that have contributed to ineffective interaction and ultimately led to the sentinel event. First of all, there is a lack of standardized information exchange between members of the multidisciplinary team. The absence of proper cooperation prevented the surgeon’s notes from reaching the nurses responsible for the patient’s preparation and recovery. If the surgeon provided relevant information to the discharge nurse regarding the earlier completion of the procedure and the need to contact the mother, this sentinel event could be prevented.

Secondly, there is a lack of controls to ensure that all the necessary documentation is checked when the patient is admitted and discharged. A lack of proper documentation resulted in misunderstanding and distress of the mother. The situation could be avoided if the hospital would have a specific, standardized action plan for the entire team to apply in the cases when the parent is not immediately available. This is evident from the words of the discharge notes, the pre-op nurse, and the registrar. Finally, the security was contacted 25 minutes after the sentinel event because there was no standard operating procedure memo for events of this type.

Fishbone Diagram of Sentinel Event Causes.
Figure 1. Fishbone Diagram of Sentinel Event Causes.

Suggested Improvements

In order to prevent future sentinel events and increase patient safety, it is essential to remove the communication barriers identified in the previous section. Hence, the first suggested improvement is to develop standardized communication protocols to ensure that patient information is available to all members of the interdisciplinary team and that there are guidelines in place to initiate a quick response to a sentinel event. Research shows that by standardizing communication between care providers, healthcare organizations can reduce errors due to miscommunication and ensure that providers can make better patient safety decisions (Burgener, 2020; Garrett, 2016; Guttman et al., 2018). Consequently, this improvement will lead to more effective interactions between patients, their family members, and the members of the interprofessional care team.

The second suggestion for improvement is to establish internal controls that could be used to guide critical processes and procedures. These include patient registration, preparation for treatment, and discharge (Burgener, 2020). For instance, updating checklists for communication and documentation during these stages of treatment could help to reduce errors and miscommunication by helping each provider to understand the required actions and their responsibilities in the process.

To enhance the interaction among the team members, it is essential to initiate training on the interdisciplinary interaction of the team. The preliminary action can involve the theoretical session for clarifying the role and ways of effective communication. The care providers should understand that their joint work would improve not only patient outcomes but also the level of their job satisfaction (Garrett, 2016). The training should also include practical sessions on resolving interaction problems that should be prepared by management and approached as a case study. Accordingly, the failures and achievements of the team should be discussed to further implement theoretical knowledge in practice.

Quality Improvement Tool

One specific quality improvement tool that would be useful both for analysis and for implementing the proposed suggestion is check sheets. According to Statit (2007), check sheets “can help make sure accurate data is collected and invites positive involvement from those who will be recording the data” (p. 13). In this way, they can assist communication between care providers and other responsible persons by ensuring that all the required information is collected, recorded, and passed on to other team members. Furthermore, check sheets can be analyzed easily as they are typically standardized (Statit, 2007). This means that they can be used for monitoring compliance with relevant standards and procedural guidelines. By ensuring that staff members use check sheets during critical stages of treatment, such as patient registration, preoperative care, recovery, and discharge, the hospital will be able to prevent sentinel events from occurring due to miscommunication or the lack of appropriate data.

Corrective Action Plan

The corrective action plan for implementing the proposed suggestions and performing a more in-depth analysis of the event can support future quality improvement efforts in the hospital. Firstly, it is recommended that an investigative committee is created to review all details of the event and gather suggestions for prevention from involved staff members. The committee should include the Chief Nursing Officer, Chief of Surgery, and the Risk Manager. Together, they should perform an in-depth analysis of the case, create new protocols for prevention, and plan the implementation of suggestions as defined in the previous section. The person responsible for the quality improvement project is the Risk Manager since managing the risks associated with sentinel events is part of their responsibilities, and they also possess the skills and knowledge required to develop and apply effective improvement plans. Metrics for tracking success should include check sheet completion rates and potential risk events reported by staff or patients. These metrics will show the staff’s level of compliance with new protocols and the effect of the plan on sentinel event risk. The expected completion date of the quality improvement project is December 1, 2020, as this will allow enough time for the committee to investigate the incident, update protocols, and collect information on metrics.

As for the specific actions to be applied to prevent similar sentinel cases in the future, the hospital’s committee should prepare a document that would clarify the expected procedures. First, all the information that is related to a patient should be available to the entire team, which can be achieved through electronic health records. For example, if a patient’s mother asks the surgeon to notify her upon the surgery completion, the surgeon should document this information, so that the discharge nurse would call her. Before accepting a child, the responsible registration nurse should collect information about the family of the child and ask whether anyone can take a child. In addition, both parents (caregivers, if available) should be notified of the medical procedures to be done for their child. The identification check should be another action to prevent the discharge to the parent, who does not have custody over the patient. Accordingly, all the team members should keep communication open and timely, documenting information in an electronic form for the most rapid access of other personnel as the actions or a lack thereof can impact those of others.

The hospital has all the necessary resources to carry out the proposed corrective action plan. The technological capacity of the institution is relatively high, meaning that electronic data collection, analysis, and reporting will be available to the committee. Additionally, the hospital should utilize its human resources to enhance the planning and implementation of this initiative. As highlighted in the interviews, the staff have potentially practical suggestions that would help to prevent the discussed sentinel event from recurring. Using their experience and familiarity with the work environment, it would be possible to identify practical and relevant tools to help prevent miscommunication in the future.

To support the actions that were proposed above, the hospital has resources to create presentations and initiate online meetings. To ensure that all the team members properly understand their responsibilities and communication importance, the hospital has an internal electronic platform for employees to ask questions and start discussions. In addition, the process change is to be supported by personnel training and further evaluation of accommodations achieved funding in terms of internal research. The risk manager should be responsible for monitoring and evaluating changes.


Overall, the sentinel event discussed in the case posed a significant risk to the patient. The interviews with responsible persons revealed critical gaps in interprofessional communication that have contributed to the event because they were not appropriately addressed. Based on the analysis of the case, it is necessary to improve the standardization and control of interprofessional communication and documentation in the hospital to avoid similar failures in the future. By implementing the proposed action plan and recommendations, the hospital will be able to protect its patients from kidnappings, thus increasing the level of patient safety.

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