Medical institutions or organizations are required to provide good healthcare quality. The analysis of sentinel is a very sensitive matter that medical officials and other role players in hospitals need to be aware of and easily respond to. The sentinel event being analyzed in this case is child abduction during child delivery. This may not have any injury or death-related implications but it has deep implications nevertheless.
Child Abduction
In the aspect of root cause analysis. Child abduction has been selected as it mainly takes advantage of the inefficiency of personnel programs. The sentinel event is not a measurable one unlike patient safety issues. Child abduction however has deep emotional implications on its victims, there is therefore a need to analyze it and provide an efficient action plan to create an effective personnel work connection during child delivery.
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Personnel involved in the sentinel event
The personnel involved in this case has been narrowed down to the officials in a hospital that carry out maternity services or ensure the services are properly carried out. There could be other parties involved, however, the parties least affect the efficiency of hospital programs in as much as they suffer their implications (Nightingale Hospital, 2018). The personnel being analyzed in this case are:
Hospital record keepers: they are very crucial in a hospital as they maintain and update the record of patients and visitors whenever need be. Considering all the people in a maternity section need to be registered or signed in, the record keepers come in handy as crucial personnel in child abduction.
Delivery nurses: Consists of pre-op, op and post-op nurses, one nurse could assume all positions when need arises. They are the main connection between an expectant mother and the delivery doctors. They execute hands-on jobs in delivery and are also there to provide that tender care to maternity patients.
Delivery surgeons: They are the technical touch in a maternity ward. Their help may be least required in good cases. The surgeons are assisted by the nurse in delivery.
Hospital/maternity security officials: Security officials are present to provide assurance of safety for all the personnel and the patients in the maternity wards. There is a need for maternity security with the increased cases of child abduction. They should monitor the premises and ensure logs of people entering or leaving the maternity sections are well handled.
Barriers that impede effective interaction amongst the personnel present
The work flow barriers affect the program efficiency. There are formulated work plans for dealing with certain jobs in the hospital. The personnel affect the efficiency of the work flow plans. The designed work flow may not favor a certain cluster of personnel at a point in the work execution. For example, the work flow pressures on nurses when the delivery surgeons are unavailable or inadequate.
The chain of command between personnel. This is affected by not just the work plan but also the authority structure of the organization. There is a need for efficiency in the transmission of orders from the top all the way down in service delivery (Berenson, Levine, Szabat, & Krehbel, 2016). For example, the reporting of cases amongst officials.
Perceptual barriers. These come as barriers that are mainly opinion involved. This is mostly a communication barrier that is affected by the change in opinion. The varied perceptions between two hospital officials could jeopardize the efficiency of the work plan. For example, a kidnapper can come posing as a parent to a security official therefore gaining his/her trust, the records could however disagree with the claims by the kidnapper therefore, the perception of the person will not be the same across the two employees.
Quality Improvement Tool
In child abduction, the best tool to use in order to improve the quality of maternity service and reduce the frequency of the sentinel events is the improvement of record checks in hospitals especially when visitations are considered. The record keepers should ensure that the details of every present individual in a maternity ward have their details recorded. The execution of this improvement tool is further discussed in the action plan.
A corrective plan towards the sentinel event
The records being observed affect the efficiency of a work flow in the maternity section. In order to curb child abduction, there needs to be an action plan that places the records of patients and visitors as the main concern. There needs to be a system that even enables the nurse check on the details of every patient or visitor. The record should also allow the entry of data for new born babies delivered in maternity wards.
What specifies that this method will work is the consideration of the abilities of the kidnapper. Most kidnappers pose as being related to patients, this should be brought to light as the patient should also agree that a visitor is indeed related to him/her and also if he/she is allowed to visit. That is where records could prove crucial.
Resources required:
Computer for central records
Computer data servers
Computer mobile devices for nurses
Software knowledge across all employees
These resources will digitize the records in a hospital and create an efficiency in a work flow plan with an aim of reducing the sentinel event of child abduction in hospitals. Most of the record sections of the hospitals have computers, so it should be no problem obtaining extra mobile devices to synchronize with the computers through the software. A wireless internet connection could be used to enable data updates be carried out more efficiently.
References
Benner, P. (2012). Educating nurses: A call for radical transformation—how far have we come? Journal of Nursing Education, 51 (4), 183-184.
Berenson, M., Levine, D., Szabat, K. A., & Krehbiel, T. C. (2016). Basic business statistics: Concepts and applications . Pearson Higher Education AU.
Nightingale Hospital (2018). Nightingale Community Health Reports.
