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Patient Safety Tip of the Week
Missing Patients
Again
A patient recently went missing from a
behavioral health facility here in New Hampshire. Fortunately, he was found
without harm. But it reminded us we have not done a column on wandering,
elopement, or missing patients in a few years. When a patient goes missing,
whether it is a behavioral health patient who elopes or a confused patient who
wanders, safety for the patient is a prime concern. Behavioral health patients
may commit suicide. Wandering, confused patients have been found fallen in
stairwells, drowned in nearby ponds, hit by cars, etc. Whenever a patient goes
missing, a prompt, well planned, coordinated response is necessary.
Fortunately,
most eloping or wandering patients are found unharmed. Healthcare facilities
need to have plans in place so that an alert can be sent out as soon as
a patient is found to be missing and a formal search be initiated promptly. Drills
for missing patients need to be practiced at least annually and should also
include your local law enforcement personnel.
Staff on the unit need to be notified as
soon as a patient is missing. A very brief head count of patients and a look into
rooms on a unit is typically done but this should last no more than a couple
minutes. At that point the hospital phone operator should be notified and code
yellow (or whatever name you use at your facility) should be announced over
the public address system. It should be announced with a brief description of
the missing patient (age, sex, race, unit, etc.). Some facilities have been reluctant to include a physical description of
the missing patient in an over-the-air announcement. In such cases, the PA
announcement can be supplemented with a blast text message to all staff that
includes a physical description of the patient (and even a photo of the patient
if one is available in the EMR, with the caveat that the patients appearance
may have changed since that photo was put in the EMR).
Exits from the building need to be
immediately locked (some doors may be locked from a central location) or manned
by designated staff members. No one should be allowed to leave the building(s)
unless cleared by a designated staff member. The operator may notify visitors
over the PA system that they are under no danger but need to avoid going near
exits for the time being. Key assigned staff should immediately go to a
designated command center from which they will direct the response.
Each unit (clinical and nonclinical) will have a specific predetermined area
they must search in a systematic fashion. The command center must have an
overlay grid of the buildings and surrounding areas and be able to mark
off areas on the grid that have been searched. The search teams must have keys
to their search areas since sometimes patients lock themselves into rooms
inadvertently. Be careful to never assume that a patient is not likely behind a
locked door.
We also recommend early outdoor search since
a patient can easily stray far from the building (or into automobile traffic)
in a very short period of time. We also recommend that the local police
department be notified immediately by the operator when the code yellow is
called (dont forget to include them in your planning process). Many facilities
also use security video cameras that are monitored centrally. Security staff
may be able to scan those quickly to look for a patient exiting the building.
Someone on the unit from which the patient
disappeared should be designated to send out a general email to all staff,
describing the missing patient and including a photograph if one is present on
the information system. The patients physician should be notified by the
operator or staff on the patient unit. Someone needs to be designated to be in
communication with the family as well. Early notification of the family is
essential, not only from a transparency viewpoint, but also because they can
help in the search and may be able to suggest areas that the patient might try
to reach.
In our
September 20, 2022 Patient Safety Tip of the Week More on Missing Patients we also noted how a
sheriffs department used a search dog and a drone in the search for a missing patient. While
initial searches are typically focused on areas inside the hospital, the
outside hospital grounds merit attention as well. Particularly if your facility
is located near a serious potential hazard like a pond or other significant
body of water, a highway, a busy road, railroad tracks, or a bridge, a drone
could provide a rapid look at such areas. A drone could obviously also provide
a flyover of the roof(s) of your facility or nearby parking garage. Just as we establish
a search grid within the hospital and assign specific individuals to search
each segment of the grid, someone capable of piloting the drone (most likely
someone in your security department) should immediately be tasked with flying
the drone over any of these high-risk areas outside the facility. This, of
course, presumes that it is both legal and safe to fly a drone in your area.
Once
the patient is found, you need to assess the patient for any potential injuries
that may have occurred. And an assessment of factors contributing to the elopement
or wandering should be done. And a critical analysis of your plan and response
should be performed.
To
facilitate the response to a missing patient, we recommend you have a readily
available checklist that has all the steps you need to take and includes items
such as the phone numbers of police and local agencies you must contact.
Robin Hattersley has some very good recommendations
in a two-part series on elderly patient elopement and wandering (Hattersley
2024a, Hattersley
2024b). Having a photo of the patient that can be released to
local law enforcement can help them identify the patient. Additionally, many
hospitals have their Alzheimers and dementia patients wear gowns that are a
specific color, which also could help first responders, as well as hospital
staff, locate the patient. And placing some of the patients personal items and
garments in a sealed plastic bag can be very beneficial because a search dog can quickly identify the patients scent.
On
admission to the hospital, patients should be assessed for risk of elopement or
wandering. Joint Commission Resources has a useful Elopement
Risk Decision Tree that you can use or modify. (Keep in mind that a patient
considered low risk on admission may have changes in status that put him or her
at greater risk later during a hospital stay.)
If
you identify a patient with confusion, dementia, hallucinations or frank
psychosis, you should consider implementing a tracking technology to help in
the case that they might wander or elope. We discussed various tracking devices
in our June 16, 2020 Patient Safety Tip of the Week Tracking Technologies. But not all are ideal for tracking the
wandering or eloped patient. The various Bluetooth or RFID devices could track
patients within the facility but do not have the sort of range youd need to
find a patient outside the facility. Some RFID solutions now incorporate
software so that hospitals and other healthcare facilities can put a virtual
fence around areas (Hattersley
2024b). GPS tracking devices would be the ideal solution, though these might be
expensive. Other options would be those trackers that are located by nearby
smartphones (such as Apples Air Tags, which use the wide network of iPhone
users locate the device).
Note
that the Emergency Department has unique vulnerabilities, particularly for
patients at risk for suicide. The ED is typically a busy place and there may be
delays in getting prompt psychiatric assessments. Patients may not get
sufficient observation while waiting for those assessments. An AHRQ
PSNet WebM&M
(Bourgeois
2023) has a nice discussion
on such cases. Our prior columns on issues related to behavioral health
patients are also listed below.
See our previous columns on wandering,
eloping, and missing patients:
·
July 28, 2009 Wandering,
Elopements, and Missing Patients
·
December
2012 Just Went to Have a Smoke
·
April 2,
2013 Absconding from Behavioral Health Services
·
October
15, 2013 Missing Patients
·
December
2013 Lessons from the SFGH Missing Patient
Incident
·
April 7,
2015 Missing Patients and Death
·
October
6, 2015 Suicide and Other Violent Inpatient Deaths
·
April
12, 2016 Falls
from Hospital Windows
·
September
18, 2018 More
on Hospital Suicides
·
January
22, 2019 Wandering Patients
·
June 16,
2020 Tracking Technologies
·
July 7,
2020 Another Patient Found Dead
in a Stairwell
·
September
20, 2022 More on Missing Patients
Some of our past columns on issues
related to behavioral health:
·
January 6, 2009 Preventing Inpatient
Suicides
·
September 22, 2009 Psychotropic Drugs and Falls
in the SNF
·
February 9, 2010 More on Preventing Inpatient
Suicides
·
March
16, 2010 A
Patient Safety Scavenger Hunt
·
October
2010 Antipsychotic Drugs and
Venous Thrombembolism
·
December 2010 Joint Commission Sentinel
Event Alert on Suicide Risk Outside Psych Units
·
September 27, 2011 The Canadian Suicide Risk
Assessment Guide
·
December 2011 Columbia Suicide Severity
Rating Scale
·
July
2012 VA
Checklist Reduces Suicide Risk
·
August
2013 Suicide
Attempts on Med/Surg Units
·
January
15, 2013 Falls
on Inpatient Psychiatry
·
April 2,
2013 Absconding
from Behavioral Health Services
·
August
25, 2015 Checklist
for Intrahospital Transport
·
October
6, 2015 Suicide
and Other Violent Inpatient Deaths
·
March
2016 TJC Sentinel Event Alert on
Preventing Suicide
·
April
12, 2016 Falls from Hospital Windows
·
May 10,
2016 Medical Problems in
Behavioral Heatlth
·
February
14, 2017 Yet More Jumps from Hospital
Windows
·
March
14, 2017 More on Falls on Inpatient
Psychiatry
·
August
29, 2017 Suicide in the Bathroom
·
December
12, 2017 Joint Commission on Suicide
Prevention
·
February
6, 2018 Adverse Events in Inpatient
Psychiatry
·
July 10,
2018 Another Jump from a Hospital
Window
·
September
18, 2018 More on Hospital Suicides
·
January
22, 2019 Wandering Patients
·
January
29, 2019 National Patient Safety Goal
for Suicide Prevention
·
July 30,
2019 Lessons from Hospital
Suicide Attempts
·
September
3, 2019 Lessons from an Inpatient
Suicide
·
February
2020 DVT and Behavioral Health
·
March
2020 Risk Factor for Preventable
Harm: Psychiatric Diagnosis
·
August
11, 2020 Above-Door Alarms to Prevent
Suicides
·
September
22, 2020 VA RCAs: Suicide Risks Vary
by Site
·
February
2, 2021 MGH Protocols Reduce Risk of
Self-Harm in ED
·
June 22,
2021 Remotely Monitoring Suicidal
Patients in Non-Behavioral Health Areas
·
November
2021 Panic Buttons to Protect
Healthcare Workers But a Word of Caution
·
April 15, 2025 Hospital Suicides
References:
Hattersley R. Responding to Elderly Patient
Elopement and Wandering: Part 1. Campus Safety 2024; August 1, 2024
https://www.campussafetymagazine.com/insights/elderly-patient-wandering-elopement/49972/
Hattersley R. Responding to Elderly Patient
Elopement and Wandering: Part 2. Campus Safety 2024; August 1, 2024
https://www.campussafetymagazine.com/news/elderly-patient-elopement-wandering/51336/
The Joint Commission. Elopement Risk
Decision Tree. Accessed April 12, 2025
https://www.jcrinc.com/assets/1/7/ECME14_Elopement_Risk_Decision_Tree.doc
Bourgeois JA, Xiong G, Barnes DK, Sandhu R. The
One That Got AwayElopement of a Suicidal Patient in the Emergency Department. AHRQ
PSNet WebM&M:
Case Studies 2023; June 14, 2023
https://psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
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