1
Root Cause Analysis
Belizath Doe
School of Business, Western Governors University
Ashley Tennessee
03/08/2026
, 2
Sentinel Event
A safety event occurred at Nightingale Community Hospital involving a 3-year-old patient
scheduled for a surgical procedure. The patient was brought to the hospital by her mother for a
surgery expected to last approximately 45 minutes, followed by about one hour of recovery time.
Prior to the procedure, the mother informed the pre-operative nurse that she needed to leave
the hospital briefly to run an errand with another sibling. She explained that she would return to
the hospital to pick up her daughter during the recovery period. The mother provided the nurse
with her cell phone number and requested that she be contacted if the surgery finished earlier
than expected. Hospital staff did not contact the mother after the procedure. Approximately two
and a half hours later, the mother returned to the hospital to pick up her daughter. Upon arrival,
the mother was informed by the hospital-discharged nurse that the child had been discharged
30 minutes earlier. (WGU, 2026)
Hospital security was immediately notified and responded by initiating a "Code Pink," the
hospital's emergency protocol for a potential child abduction. The hospital security notified local
law enforcement, and they responded to assist with the situation. During the security officer's
interview, the mother disclosed that she and the child's father were divorced and that she had
full custody of the child. Within 30 minutes of the report, the patient was found at the father's
residence. The child was safe and waiting for her mother to arrive. Law enforcement determined
that no criminal charges would be filed against the father. Following the incident, the Nightingale
Chief Executive Officer contacted the mother directly and assured her that the incident would be
investigated. The hospital is committed to reviewing the circumstances of the event to identify
procedural failures and implement corrective measures to prevent similar incidents in the future.
(WGU, 2026)
Root Cause Analysis
Belizath Doe
School of Business, Western Governors University
Ashley Tennessee
03/08/2026
, 2
Sentinel Event
A safety event occurred at Nightingale Community Hospital involving a 3-year-old patient
scheduled for a surgical procedure. The patient was brought to the hospital by her mother for a
surgery expected to last approximately 45 minutes, followed by about one hour of recovery time.
Prior to the procedure, the mother informed the pre-operative nurse that she needed to leave
the hospital briefly to run an errand with another sibling. She explained that she would return to
the hospital to pick up her daughter during the recovery period. The mother provided the nurse
with her cell phone number and requested that she be contacted if the surgery finished earlier
than expected. Hospital staff did not contact the mother after the procedure. Approximately two
and a half hours later, the mother returned to the hospital to pick up her daughter. Upon arrival,
the mother was informed by the hospital-discharged nurse that the child had been discharged
30 minutes earlier. (WGU, 2026)
Hospital security was immediately notified and responded by initiating a "Code Pink," the
hospital's emergency protocol for a potential child abduction. The hospital security notified local
law enforcement, and they responded to assist with the situation. During the security officer's
interview, the mother disclosed that she and the child's father were divorced and that she had
full custody of the child. Within 30 minutes of the report, the patient was found at the father's
residence. The child was safe and waiting for her mother to arrive. Law enforcement determined
that no criminal charges would be filed against the father. Following the incident, the Nightingale
Chief Executive Officer contacted the mother directly and assured her that the incident would be
investigated. The hospital is committed to reviewing the circumstances of the event to identify
procedural failures and implement corrective measures to prevent similar incidents in the future.
(WGU, 2026)
