A Root Cause Analysis of a Child Abduction at Nightingale Community Hospital

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Nightingale Community Hospital is performing a root course analysis of a pediatric abduction that took place in the facility when Tina Gerhardt a three-year-old was wrongfully discharged. A sentimental event is an adverse occurrence in the healthcare delivery service, which has a potential to lead or led to a catastrophic outcome, thereby prompting an initiation of prevention measures or emergency intervention. These events are referred to as sentimental because they signal the need for immediate response for instance investigation as well as finding solutions to prevent a repeat of such scenarios. In the case study, the three-year-old Tina Gerhardt was admitted. The mother left the kid in the hands of physicians because she needed to run a quick errand that involved older siblings. The mother was informed by the physicians that the surgery could last for about 45 minutes. The mother left but promised to return and pick up the child once the surgery was over. Before she left, the mother left her personal contact with the nurse. She instructed the nurse to contact her in an event that the child left the surgery room sooner than expected.

The mother failed to respond after the surgery despite the fact the nurse made attempts to call her out in the waiting area. The child was later on taken to the discharge area. Coincidently, the father of the child was in the waiting area and the nurse gave him an opportunity to see the patient. The discharge nurse was relieved because the child became excited and called the man daddy. The father was allowed to take the child home after waiting for the mother for 30 minutes. The nurse provided the father with all the discharge papers. Upon the mothers return two and half hours later a hospital-wide child abduction alert was raised. It was noted that the child had been discharged thirty minutes earlier. The police responded immediately to the distress call and started searching for the child. The child was located 30 minutes later at the father's domicile. The healthcare chief executive officer apologized to the mother and promised her the event would be reviewed with the objective of preventing such an occurrence in future. No, the charges were pressed against the father.

Role and Responsibility

Based on the interviews, the child was taken by her mother to the registrar. The major role of the registrar is to collect the patient insurance, demographic and identification data. The registrar also makes sure that the consent for payment and admission are filed as required (Izedi & Bahrami, 2016). During the interview, the registrar stated that she performed her duties as expected.

The pre-operative nurse also conducted her duties as expected. After receiving the patients she performed a pre-operative nursing assessment. She obtained an official hospital gown for the patient, documented in the patient records, oversaw the patient’s pre-operative medications, initiated an intravenous infusion, and made sure that the parents signed the consent form. The nurse also recorded the cell phone number of the mother because the mother indicated that she would return to pick up the child later after the surgery. The pre-operative nurse later on handed over the child to the operation room.

Operating nurse duties include evaluation, diagnosis, and assessment of the patient throughout the operative procedure until the patient recovers. In the interview, the operating nurse has nothing factual about the event but stated her facts about the potential prescription factors that will be addressed at a later stage in the report.

The recovery nurse (RN) is mainly familiar with the side effects associated with anesthesia and understands the steps that are required to mitigate the side effect of anesthesia and to allow the patient to recover. In the interview, the RN stated he took over from the operating report nurse and even tried to trace the patient’s mother. He started he waited for the patient to recovered before handing her to the discharge nurse.

The discharge nurse is responsible for conducting nursing assessments as well as executing the orders of the doctors even as the patient prepares to be discharged. The discharge nurse also assesses the paperwork and ensures a smooth handoff between the parent and the staff. Moreover, the discharge nurse is responsible for ensuring that the parents understand all the discharge instructions. In the interview, the discharge nurse states that the child became excited when she saw the father and even called him dad. Since the mother had not returned after more the 2 and half hours, the father offered to take the kid home and the discharge nurse accepted. The discharge papers were issued.

The surgeon is responsible for performing surgical procedures on the patients. In addition, the surgeon ensures that the healthcare facility appropriately prepares the patient. This can entail providing any notes on the anomalous that is associated with the patient care. In the interview, the surgeon did not offer much information.

The police are responsible for maintaining law and order as well as ensuring that patients are safe. The police are supposed to respond timely to any high-risk scenarios that are presented in the hospital in this case they are supposed to execute exercises as a way of testing their preparedness. The police are also supposed to identify any risk factors and recommend for any solutions to the management. The police are supposed to work in collaboration with the hospital staff to achieve compliance and spread awareness. In the case, once the distress alarm was raise concerning the child’s abduction, the police responded promptly.

The chief nursing executive (CNE) is also involved in this incidence. The CNE is responsible for maintaining patient’s care and clinical standards. To achieve this, they work in close collaboration with the other nurses. They are also mandated to handle nursing strategies. They conduct the evaluation and assessment to gauge the efficiency of various departments within the facility.

Barriers to Effective Interactions

There are numerous factors that can hinder a smooth interaction in the hospital. Job stress is one of the factors that can lead to ineffective communication (Childs, 2015). If employees become overwhelmed in their current jobs they might not communicate effectively with others. Stressful jobs can make workers overlook certain procedures that can lead to sentinel events.

Lastly, interpersonal factors also contribute to job dissatisfaction. Each individual’s level of self-esteem will be portrayed in other by the communication signal they portray. An ineffective communicator might not perform well in a group. In addition, an individual with low self-esteem might never communicate openly with others.

In the case presented pertaining to Nightingale Community Hospital the elements of ineffective interactions have been presented. The pre-operative nurse stated in her statement that she does everything alone. This is one of the stressors as well as the reason that made her not to pass the mothers phone call number to the operating nurse. In the case of the registrar, education can be seen as a factor that contributed to the incidence. She noted that she followed the due process just as they had been trained. She might not be satisfied by her job because she only performs tasks up to the limits set.

Ways to Improve Interactions

The management ought to build a team spirit among the worker by creating an environment where all individuals feel they are part of the hospital. Employees want to feel they know what is going on in the entire firm. This makes them feel important. The management should ensure they communicate with all individuals in the loop. Team bonding can be used to improve the communication channel in the organization.

Firms have to endeavor to train that encourages individual employees to communicate with each other. The training will encourage workers to speak up and ask for help when necessary (Ghobadi & Mathiassen, 2014).

Quality Improvement Tool

The Fishbone diagram will be used for this root cause analysis. Process chart will be utilized to visualize the entire process. The diagram provides an opportunity for the team members to visualize the factors that contributed to a certain incident. The healthcare facility will rely on the four P’s: People, Plant, Procedure, and Policy. For each of the causes, the employees might question why they exist. This will enable them to identify the root cause. The flowchart provides the team with an opportunity to see the entire process in a multidisciplinary fashion meaning they can discuss areas that require improvement.

Fishbone Diagram


(Shinde, Ahirrao & Prasad, 2018)

Corrective Action Plan ("Risk Management, Disaster Planning and Protecting Against Crime,” 2018)

1. Issue: the hospital has to identify the parent or the guardian of a child to prevent potential abduction.

i. Action:

a. Implementation of the abduction alarms in the highly risky areas

b. Indicate all area where the minors are at a higher risk of being abducted

c. Adjust the policies that require thorough identification before minors are discharged.

d. Adjust the policies that require identical banding of legal guardians and minors.

e. Adjust policies that require band check before the patients are discharged.

f. Implementation of policies that requires the registration personnel regarding the legal guardian to pass all the information regarding minors to the discharge nurse.

ii. Implementation Timelines

a. Adjustment of the policies ought to be immediate.

1) Resource required: the management should change the policies within the shortest time possible. The resources include the chief executive officer and the employees.

b. Training on policy adjustment has to be prompt immediately after the policy has been adjusted.

1) Resource required: training material, financial resources, and time during the training process to give workers to undertones the changes.

c. The nursing tool adjustment must be done within the shortest time possible.

1) Resource required: documentation, educational faccilities as well as administrative change form

d. Purchase of an alarm should be done within the first month

1) The resources required: time for training the personnel, training, and installation as well as allocating funds for the purchase.

e. Training for improving communication between the registration personnel regarding the legal guardian to the preoperative and discharge nurse will be done with the first three weeks.

1) The resources required: time for training, altering the internal policies and respective nurses.

iii. Monitoring

a. Assessment drills can be conducted on regular basis to ensure that all employee are conversant with the changes. The employees must understand their responsibilities during a child abduction incidences.

b. Minoring exercise should be continued until all the employees understand the procedures.

iv. Only 100 percent understanding of the policy will be accepted in this area.


Childs, J. (2015). Blogging as a tool to address communication challenges among nurses. Nursing Management (Springhouse), 46(11), 53-54. doi: 10.1097/01.numa.0000472770.96106.ed

Ghobadi, S., & Mathiassen, L. (2014). Perceived barriers to effective knowledge sharing in agile software teams. Information Systems Journal, 26(2), 95-125. doi: 10.1111/isj.12053

Izedi, R., & Bahrami, M. (2016). The Correlation of Nurses' job Burnout and Their Social Responsibility Considering the Role of Control Locus. Bali Medical Journal, 5(2), 152. doi: 10.15562/bmj.v5i2.258

Risk Management, Disaster Planning, and Protecting Against Crime. (2018). Retrieved from https://managementhelp.org/riskmanagement/index.htm

Shinde, D., Ahirrao, S., & Prasad, R. (2018). Fishbone Diagram: Application to Identify the Root Causes of Student–Staff Problems in Technical Education. Wireless Personal Communications, 100(2), 653-664. doi: 10.1007/s11277-018-5344-y

January 19, 2024

Crime Health Family



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Child Abuse

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