What’s New in the Patient Safety World

December 2013

Lessons from the SFGH Missing Patient Incident



Our October 15, 2013 Patient Safety Tip of the Week “Missing Patients” had numerous recommendations about steps to be taken when a patient goes missing. That column was an update to our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients”. We did the update because of the recent events at San Francisco General Hospital where a patient was found dead 17 days after going missing. We had hoped that details of their investigation would be shared so that other hospitals could learn from this unfortunate incident. However, details have been slow in coming and all we’ve seen are fragments published in the local media. Nevertheless, there are probably some lessons learned even from those few fragments.


Like any other incident with adverse patient outcomes we typically see a cascade of events that come together to allow that unfortunate outcome.


A timeline of the events in this case was presented by the Sheriff whose department oversees the security at SFGH (Yan 2013).


From descriptions in the media it does not sound like there was ever a point in time where someone said “We have a missing patient. Activate our missing patient protocol and procedures.” Apparently about 40 minutes went by before the hospital’s security staff was notified the patient was missing (Van Derbeken 2013). A nursing assistant had been looking for her unsuccessfully during that period. One likely contributing factor was that the patient apparently was being considered for discharge that day. When the physician went to see the patient prior to the planned discharge, the patient was already gone. That planned discharge and fact that she was not subject to a psychiatric “hold” apparently led to Sheriff’s Department deputies (the security for SFGH is provided by the Sheriff’s Department) to not really consider handling the case as a missing patient.


The attorney for dead patient’s family said the hospital should have known much sooner that one of its patients was missing. He pointed out that hospital staff had deactivated the patient’s bed alarm because she kept getting up (Palmer 2013).


Next, there was confusion over the description of the patient. Various reports to the Sheriff’s Department described her as Asian or African-American though she was white. (As per our previous columns, is this an example where having a photograph of the patient might have helped?) It was also unclear whether she was in street clothes or hospital gown.


Other communications issues include that the evening shift deputies stationed at the hospital were not briefed by previous deputies about the missing patient (Yan 2013).


Deputies tried to retrieve hospital surveillance-camera footage for clues of where the patient had gone, but "hardware problems" prevented them from doing so and it was over a week before those videos became available.


When searches were eventually done, they were incomplete. The perimeter of the 24-acre hospital grounds was searched and only about half of the stairwells were checked.


The Sheriff indicated some changes have already been implemented (Romney 2013). One is mandated daily patrols of fire stairwells. Another is required documentation of responses to “stand alone audible alarms” (which presumably would have occurred when the patient exited into the stairwell). Apparently none of the stairwell door alarms were deficient, broken or inoperable; they just weren’t all set to require manual deactivation (Sherbert 2013). Apparently now when those alarms ring, security staff will check each one, and nurses will make sure all unit patients are accounted for, as part of a new policy (Hoenen 2013). The video surveillance system is apparently also being reviewed for possible upgrade.


Also, a visitor to SFGH apparently noted that she had found herself locked in a similar stairwell at the hospital several months earlier (Rosato 2013). She had decided to skirt the elevator and walk down the stairs. There apparently were no signs that the doors would automatically lock. She had to bang on the doors until, finally, a nurse came and opened the door. We’ll bet you might have similar locked stairwells in your facility. Ask your security staff if they have ever received a cell phone call from someone locked in such a stairwell!


Not fully clear from the media are issues related to staffing of the security department of the hospital. Apparently the Sheriff’s Department is responsible for providing the security at the hospital. But the levels of training of that staff are apparently quite variable (Lamb 2013). The media reports do not detail the degree of continuity of security staff or whether all staff have participated in drills for missing patients. But apparently a number of changes are taking place in the deployment of staff and training and retraining.


It is also not clear whether all hospital staff are involved in a “missing patient” event. From the media descriptions it sounds like the security staff were expected to do everything. In a “missing patient” event, for which regular drills should be conducted, all hospital personnel must be cognizant of their role. Typically, designated staff have responsibilities to search specific sectors in a “grid” search. And there should be a “command central” which coordinates the search and records which areas of the facility and grounds that have been searched.


Now is a good time for all facilities to say “could that happen here?” and do a thorough review of your policies and procedures for missing patient incidents, including making sure you do appropriate drills for such incidents. Take the opportunity to learn from the events at SFGH in their unfortunate incident. We urge you to review the recommendations in our Patient Safety Tips of the Week for July 28, 2009 “Wandering, Elopements, and Missing Patients” and October 15, 2013 “Missing Patients” about steps to be taken when a patient goes missing.







Yan H. Body found in hospital stairwell: San Francisco sheriff details what went wrong. CNN; November 7, 2013




Van Derbeken J. Deputies missed stairwell in search for missing woman at Calif. hospital. San Francisco Chronicle; November 7, 2013




Palmer C. Lynne Spalding: Sheriff Tries to Explain How Deputies Overlooked Missing Patient. SF Weekly Nov. 6 2013




Romney L. Sheriff cites confusion, glitches in search for missing patient. LA Times. November 6, 2013




Sherbert E. Lynne Spalding: Here's What SFGH Is Doing to Make Hospital Safer After Missing Patient Found Dead. SF Weekly Nov. 7 2013




Hoenen L. Security failure blamed for patient’s death. San Francisco hospital overhauls procedures, awaits review results. Security Director News; November 11, 2013




Rosato J. SF General Visitor Says She Also Was Locked in Stairwell: Report. NBC Bay Area October 23, 2013




Lamb JO. Some San Francisco hospital security performed by low-level officers.

San Francisco Chronicle November 8, 2013





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