New Policy??

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So a hypothetical situation here...This is a homework question with a quick answer! Yes, I googled it but I must not be using the right search term because I can't find the answer. Anyway, say a child was released post op to her non custodial father, creating a JCAHO sentinel event. In my action plan I, of course, included the need for yet another new policy. Now, who would be the one to actually develop that policy? Would it be legal, risk, admitting, CEO/Admin, HR, or???

TY for your help

Specializes in ER, Trauma.

I'd say it's an admitting problem. They have the initial contact and the opportunity to get things sorted out before the fact. Of course legal will have to be consulted, but getting a clear, concise, understandable answer from a lawyer is something that I've never been able to do.

Specializes in ICU, Home Health, Camp, Travel, L&D.

Sounds like a nursing issue...when we do admission in the Women & Children's Pavilion we find out and flag custody issues. The kiddo has to go home with only approved parent/gaurdian. Admitting is doing well to get the current address right on the face sheet, please don't trust them with an issue this big.

Maybe instead of a new policy and yet another piece of paper, your crew needs an inservice.

Specializes in Hospital Education Coordinator.

as a pedi nurse I would have patients lie to me about who has custody. Therefore, the policy could be done as a nursing dept policy, but risk mgmt should certainly be involved to be certain state laws are followed.

Specializes in Med-Surg, Psych, Tele, ICU.

risk management and legal.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
So a hypothetical situation here...This is a homework question with a quick answer! Yes, I googled it but I must not be using the right search term because I can't find the answer. Anyway, say a child was released post op to her non custodial father, creating a JCAHO sentinel event. In my action plan I, of course, included the need for yet another new policy. Now, who would be the one to actually develop that policy? Would it be legal, risk, admitting, CEO/Admin, HR, or???

TY for your help

In the presence of a sentinel event there would be a root cause analysis where all staff and departments involved are present to see what went wrong and how to improve the process. These are not meant to be finger pointing pow wows but a fact finding get together to improve the rpocess. The department involved would begin the policy....let's say PEDI. The manager, staff, educator, director and medical chair would develop the early plan. Then Risk management and legal would get involved to try to idiot proof, I mean close loop holes in the policy. Then the policy would be presented to all department managers for approval or suggestions and finally to be approvd by nursing admin, CEO, medical MD chief's, and HR before entering the policy books.

There maybe slight variations from facility to facility but this is a pretty good representation!!

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