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Patient Safety Tip
of the Week
December 20, 2011 Infant Abduction
In our November 17, 2009 Patient Safety Tip
of the Week “Switched
Babies” we
noted that, for at least the last 10 years, most hospitals have had
fairly sophisticated systems in place to avoid infant abductions and to respond
promptly if one occurs. And most hospitals feel confident with those systems.
However,
all it takes to shake that confidence is reviewing an infant abduction that
takes place elsewhere. You’ll find yourself saying “Wow. I wonder if that could
have happened here.”
Every
year about this time the California Department of Public Health releases a
report on significant incidents that have taken place in California hospitals.
We read them, not to see which hospitals have had such events, but rather to
look at the root cause analyses (RCA’s) that were done. There are so few
publicly available RCA’s yet the lessons learned from them can be very powerful
and applicable at hundreds of other hospitals. In the group released this year,
one dealing with an infant abduction really got out attention.
Briefly,
an individual dressed in scrubs entered the room of a mother and newborn,
identified herself as a student nurse and told the mother she needed to take
the infant to be footprinted. The individual was able to completely exit the
hospital with the abducted infant in a large handbag/tote.
When
a real hospital nurse entered the room and found the bassinette empty except
for the intact infant security band, a “Code Pink” was immediately initiated.
Authorities
were able to reconstruct the movements of the abductor through review of
various surveillance videos and the individual and the infant were eventually
tracked down because the parking lot attendant wrote down the license plate
number when she had no money to pay her parking fee.
But
as you read through the health department’s description of the incident and
contributing factors and the hospital’s plan of correction you will likely find
yourself saying “that could have been us”.
The
abductor had been seen on the mother infant unit (MIU) on at least 3
consecutive days prior to the abduction. Each time she was dressed in a nurse’s
uniform or scrubs. When asked by staff what she was doing there her reply was
“visiting a friend” but no one apparently ever questioned who the friend was.
There was no security guard on the unit at the time and apparently no access
control policy. The video surveillance system was not actively monitored but
rather only used for retrospective viewing if the need arose. There were also
apparently multiple points of potential entrance and egress to and from the MIU
(including stairwells, elevators, etc.). The stairwells were not equipped with
door alarms or one-way locks to restrict access to the MIU. And the only alarm
system would be triggered by the infant security band (a tag transmitter band),
which had been removed intact in this case. An alarm would also be triggered if
this security band is broken but in this case the abductor was able to remove
the security band from the infant’s ankle intact.
Apparently,
nursing staff were expected to serve as the access control mechanism but there
was apparently suboptimal training for that. Additionally, when all nurses were
busy there would be no one accountable for access control. There was also no
signage identifying the unit as having restricted access and requiring visitors
or non-authorized personnel to check in at the nurses’ station. The facility
did have a visitors’ hours policy but it was seldom enforced (the event took
place outside of the visitors’ hours in that policy).
Nurses
on the MIU wore the same uniform and standard hospital badge used by all other
nurses in the hospital. There was no distinctive feature that identified them
as belonging on the MIU. Similarly there were no distinctive features that
would identify personnel who could transport an infant in the hospital.
The
hospital did regularly conduct drills on their “Code Pink”. In fact, they did 4
in the two years prior to the incident. In each of those 4 drills, the
“abductor” was able to successfully exit the facility. Numerous drill
evaluations were either incomplete or identified items needing improvement but
lacked verification that those items were corrected.
The
hospital’s “Code Pink” response began with notification of the switchboard by
dialing “599” and giving a specific location. The switchboard operator would
then send out a group page. This was apparently a “silent” page that would be
delivered to designated cell phones as a text message. There apparently was no
hospital-wide overhead page or alert given. If cell phones were not
operational, no message would be delivered.
The
“Code Pink” policy did have specific assignments for staff on the various
units. Security would respond to the location, call 911 and notify the security
manager and VP of facility management. Facilities management staff would meet
at a designated location and be assigned to various posts throughout the
facility. And although the policy stated that all possible suspects would be
stopped and detained, there was no formal training on what to look for, what a
“possible suspect” looked like, and what to do if they stopped someone.
In
the actual event, the request did go to the switchboard operator to send out
the silent alarm. However, several attempts failed to get out the specific
message. Apparently prior discussions about scripting messages for the
operators had never been followed up on.
The
adjacent parking structure was operated by an independent company. None of the
parking attendants, nor the valets who sometimes parked cars for patients and
visitors, had ever been included in training for “Code Pink” events.
Fortunately, the parking lot’s own procedures for dealing with patrons unable to
pay included writing down the license plate number and that facilitated finding
the abductor and infant.
There
was also no documentation that parent awareness training (including infant
security and safe transportation guidelines within the hospital) had taken
place.
There
were also apparently 26 hospital exits in all.
The hospital
response included multiple interventions to control access. These included
better signage restricting visitors and unauthorized persons, institution of
greeters, more strategically located security guards, and visitor logs and
visitor badges. They also added alarms and locking devices for stairway doors
and redeployed surveillance video cameras. They educated staff, including
warnings not to let others “tailgate” them as they exited elevators to
restricted areas and educated the community about new security issues in the
hospital. They issued unique identification badges to identify staff working on
special units like the MIU.
They
also instituted procedures to verify tight fit of the infant security bands and
switched to a new security band that can be tightened if the infant loses
weight.
They
made their “Code Pink” policies more in keeping with the NCMEC (National Center
for Missing and Exploited Children) guidelines for missing/abducted children,
redid their messaging system and redid their lockdown procedures, including the
parking facility in those lockdown requirements. The parking lot staff and
valet parking staff were also included in “Code Pink” training and responses.
They
standardized written education materials for parents on infant safety and
included information on infant security in pre-natal materials to give to
parents prior to their labor and delivery. They also developed ways to use the
EMR for more detailed description of infants (birthmarks, eye color etc.) and
developed policies on holding cord blood for DNA testing, if necessary.
Code
Pink drills were also improved by adding specific observers and development of
standardized forms to be filled out by observers.
So,
do any of these factors apply to your facilities and organizations? We see many
recurrent themes that occur at multiple hospitals:
- Hospital switchboard operators are so
critical to a variety of different “codes” yet their involvement and training
is often an afterthought.
- Bringing non-hospital personnel into
training for your “codes” is often overlooked (see our October 25, 2011
Patient Safety Tip of the Week “Renewed
Focus on MRI Safety”
for another example of how failure to integrate hospital and
non-hospital personnel into safety issues can be problematic).
- Take a few minutes some day and see how
many non-employees have access to your facilities, including “restricted”
areas.
- Do you really have an access control
system in place?
- How many of you thought that your infant
security bands were “failsafe”?
- How difficult would it be to slide off
an infant security band intact?
- Do you have systems in place that ensure
action items identified in reviews of your various drills actually get
incorporated into you policies, procedures and practices?
- How do you deploy observers for your
drills and what do you have them look for?
- When do you educate your moms (and dads)
on security issues related to newborns?
- Are you sure that moms understand (i.e.
that medications have not impaired their ability to understand)?
- Do you have some special means of
identification of personnel who should have access to your restricted
units?
- Do you have too many entrances and exits
in your facility that could be accessed without an ID badge or other
device?
- Would you allow a visitor to bring a big
tote bag or duffle bag into any area of the hospital?
The Joint Commission issued a Sentinel Event
Alert in 1999 that identified root causes in cases of
infant abductions from hospitals and made numerous recommendations for steps to
prevent such. Among those recommendations were attaching secure identically
numbered identification bands to the baby (wrist and ankle bands), mother, and
father or significant other immediately after birth. In addition, the footprint
of the infant and a color photograph of the infant are recommended. Some
hospitals also use a fingerprint of the mother in the identification process.
Prompt recording of the physical examination of the infant is also useful in
the identification process (eg. recording of birthmarks may be very helpful in
correct identification). Code Pink policies also include conspicuous
identification badges for all staff members, good security/surveillance of all
access and exit sites, and high tech infant security tags and alarm systems.
Note also that you may wish to modify your “Code Pink” policy to also include
patients who have eloped or are otherwise missing (see our July 28, 2009
Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients”).
Education
of both staff and the family are important in preventing infant abductions but
should also be extended to help prevent incorrect identification of infants.
When providing such education to mothers and family, it is important to assess
their level of understanding. It is wise to do that education twice with the
mother, once in the days or weeks just prior to anticipated delivery and then
again immediately after delivery when the ID tags are being placed. You need to
keep in mind that the mother’s cognition may be impaired by drugs used during
labor and delivery and she may not fully comprehend what she is being told at
that time. In any case, the identification process should be reinforced on
every interaction between mother and baby and staff.
The
hospital’s plan of correction in the current incident also relied heavily on
information and recommendations from the National
Center for Missing and Exploited Children.
While
we previously had thought that doing a FMEA (failure mode and effects analysis)
on the possibility of switched babies was likely to be more fruitful than doing
one on infant abduction, this incident raises so many questions about potential
vulnerabilities that it is a great topic for a FMEA.
Are
you really sure this couldn’t happen at your facility?
Update:
See also our September 4, 2012 Patient Safety Tip of the Week “More Infant Abductions”.
References:
California
Department of Public Health. Event ID: XEH111 April 25, 2011
The
Joint Commission. Sentinel Event Alert. Infant Abductions: Preventing Future
Occurrences. Issue 9 April 9, 1999
National
Center for Missing and Exploited Children
https://www.missingkids.org/home
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