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Patient Safety Tip
of the Week
November 3, 2020
Reminder:
Infant Abduction Risk
A
recent infant abduction is a stark reminder that your organization can be
vulnerable even when it thinks it has all appropriate preventive measures in
place. A 35-year old man abducted a newborn infant in a back pack from a
Louisiana hospital (Segura 2020a, Segura 2020b, Cole 2020, Onken 2020). The baby was found safe a few hours later
and the man was subsequently arrested.
The hospital had multiple measures in place for infant
safety. Visitors are required to have a photo ID at arrival when check-in. The
“Safe Place” infant security system was in place with sensors in place
throughout the organization that track the baby as it moves from one place to
the next. That system sends alerts and there are panels at the nurses' station
as well as the security department that trigger alerts to the staff, Security
bracelets are put on the babies until they’re discharged. According to arrest records, an alarm did sound
notifying the hospital staff that the security bracelet had been removed, but
the baby was gone by the time staff arrived. Records state that the bracelet
was found in the trashcan. The mother was not cooperative, according to authorities.
Records said the suspected abductor entered the hospital room just after 11
p.m. He left the room with a book bag about 10 minutes later. The baby was
taken from the hospital just after 11:20 PM and state police issued a Level II
Endangered/ Missing Child Advisory and the baby was found safe a few hours later
and the man, who was the father of the newborn, was subsequently arrested.
According
to court records, the baby’s mother had tested positive for THC and amphetamines
and there was a possibility the baby would be taken by the Department of
Children and Family Services (Segura 2020b).
The
hospital had a similar newborn infant abduction four years earlier (KNOE News 2016). That led to implementation of the “Safe
Place” infant security system. The hospital also provides ongoing education and
training drills to all team members to ensure the safety of all patients.
SAFE
PLACE® is an RFID-based infant security system (and
can also be used for older patients who might be at risk for elopement). Patients
wear small, lightweight transmitters that continuously “check-in” with the
system. If a patient is too close to a monitored exit, doors lock, an alarm
sounds and staff members are instantly notified, all via their wireless
devices. It is the type of tracking system we advocate, not only to protect
against infant abductions, but also to identify wandering patients with
dementia or delirium, or detect elopement in patients on behavioral health
units (see our June 16, 2020 Patient Safety Tip of the
Week “Tracking Technologies”).
But
the current Louisiana case shows there are important considerations beyond just
implementation of such systems. While removal of the bracelet triggers an alarm,
the delay in responding to the alarm could allow enough time for the abductor
to leave with the infant, as happened in this case. Fortunately, hospital video
monitoring identified the perpetrator and staff was able to tell authorities
who had been visiting the mother.
Another question to ask is “What happens if a fire alarm
has gone off?”. We’ve mentioned in several columns on patient
elopements use of fire alarms to both serve as a distraction and to
automatically unlock doors. For that reason, we recommend that hospitals
occasionally perform drills where they tie a “Code Pink” (or whatever you call
your infant abduction alert code) or “Code Yellow” (or whatever you call your alert
for missing patients) to your fire drills.
The abductor in this case does not fit the profile of the “typical”
infant abductor. The National Center for Missing & Exploited Children (NCMEC
2018) describes
the characteristic of the “typical” infant abductor:
- Usually
a female of childbearing age who appears pregnant.
- Most
likely compulsive; most often relies on manipulation, lying and deception.
- Frequently
indicates she has lost a baby or is incapable of having one.
- Often
married or cohabitating; companion’s desire for a baby or the abductor’s
desire to provide her companion with “his” baby may be the motivation for
the abduction.
- Usually
lives in the community where the abduction takes place.
- Frequently
initially visits nursery and maternity units at more than one health care facility
prior to the abduction; asks detailed questions about procedures and the
maternity floor layout; frequently uses a fire exit stairwell for her
escape; and may also try to abduct from the home setting.
- Usually
plans the abduction but does not necessarily target a specific infant;
frequently seizes any opportunity present to abduct a baby.
- Frequently
impersonates a nurse or other allied health care personnel.
- Often
becomes familiar with health care staff members, staff member work
routines and victim parents.
- Often
demonstrates a capability to provide care to the baby once the abduction
occurs, within her emotional and physical abilities.
For
those infants abducted from healthcare facilities, the abductor most often
impersonates a nurse or other healthcare worker (72.53%), or a relative, friend
or acquaintance (14.29%), someone involved in business-related interactions
with the mother (i.e. advertising, selling, or purchasing) (4.40%), or someone
from Social Services, INS or other government entity (2.20%).
The 2016 newborn infant abduction at that Louisiana hospital
(KNOE
News 2016) better fit with the “typical” pattern. A 24-year
old woman entered a hospital room occupied by a mom and her three-day old
infant. She told the mother a mutual friend sent her there with a baby bag. The
two talked for a little while, and when the mother got up to use the bathroom,
she returned to find the baby gone. Hospital staff, security, and police were
notified, and began investigating. A hospital employee recalled dealing with a
patient earlier in the day, talking about pregnancy issues. Police would later
connect that person to that conversation, after finding out she had been
treated in the hospital several hours prior to receiving the initial kidnapping
call. Investigators contacted the suspect's mother at her home. Shortly after,
an unknown woman came to the suspect's mother's home and surrendered the baby.
Police say the child appeared in good health and unharmed, and afterwards, was
reunited with his mom. Video footage from the hospital showed that suspect
leaving with the child, which led to a warrant being issued for aggravated
kidnapping.
A
2007 article (Miller 2007) still provides some very practical
recommendations:
- Staff should learn to be suspicious of
anyone who visits the unit repeatedly but isn't
visiting a specific patient. A potential abductor may study the unit
layout, learn when staff goes into patient rooms, and ask questions about
feeding times or nursery location.
- Anyone carrying an infant in her arms
(rather than in a bassinet) or carrying large bags or packages should
raise a red flag.
- The abductor may target a patient room that's far away from the nurses' station or that's near
an exit, stairway, or elevator.
- She may also create a diversion (or have
an accomplice create one) so that she can escape unnoticed with the
infant.
It
also had recommendations to tell the parents:
- If they want to walk with their infant,
he should be in the bassinet and not in a parent's arms.
- The infant's security band must remain attached to his wrist or ankle at all times.
- Call a nurse right away if the baby's
band comes off. The nurse should replace it immediately in the presence of
both parents, if possible.
- Know your name and the names of other unit
staff who might take the baby to the nursery or to another department for
tests. Familiarize them with unit ID badges.
- Ask to see identification of anyone who
comes to look at the baby or take the baby to the nursery.
- Any time a parent feels uncomfortable
with someone who's in the room, she should press
the call bell to summon a staff member.
- The unit routine should be written on a
whiteboard in the patient's room. When the parents know the unit's
routines, they're more likely to notice when
something isn't right.
The
Miller article also had recommendations from a since-retired Joint Commission
Sentinel Event Alert:
- Attach secure identically numbered bands
to the infant (wrist and ankle bands), mother, and father or significant
other immediately after birth.
- Footprint the infant, take a color
photograph of him, and record his physical examination within 2 hours of
birth.
- Implement an infant security tag or
abduction alarm system, such as a bar-coding system or umbilical clamp,
which triggers an alarm, locks doors, and freezes elevators if the infant
comes within 4 feet of an exit or elevator.
- Transport infants only in bassinets; don't allow them to be carried or left in the hallway
without direct supervision.
- Establish a tracking system to document
where the infant is at all times.
- Require staff to wear up-to-date
conspicuous, color-photograph ID badges and require staff in direct
contact with infants to wear a second form of unique ID, such as a badge
with a pink background.
- Don't publish
birth announcements in local newspapers. Don't
post the full names of mothers or infants where other patients or visitors
can see them.
- Control access to the maternity unit;
for instance, keep all unit exit doors locked and make sure they're monitored by video surveillance cameras with a
date/time stamp.
Our December
20, 2011 Patient Safety Tip of the Week “Infant Abduction” also had examples of cases where infant
abductions took place despite hospitals having in place similar bracelet-based
alert systems. We hope you will go back to that column and also our September
4, 2012 Patient Safety Tip of the Week “More Infant Abductions” for our multiple recommendations on
prevention of infant abductions.
- What
if…the bracelet security system failed?
- What
if…the exit doors unlocked automatically during a fire alert?
- What
if…staffing was low due to an unexpected absence and we now get an emergency
C-section?
- What
if…an infant has to go to radiology for a study?
- What
if…a doctor tells us “it’s okay to let the father carry the infant to
radiology”?
- What if…the Wi-Fi system went down?
- 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?
- What
would the response be if a security band was
removed?
- Do
you have systems in place that ensure action items identified in reviews
of your various drills actually get incorporated
into your 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
whole point of a FMEA is to identify areas where unexpected circumstances might
occur that could breach your safety processes.
As we
said in our September 4, 2012 Patient Safety Tip of the Week “More Infant Abductions” “First and foremost don’t get
complacent!” All too often we hear “that could never happen here” and
people assume that the infant security bracelet system is failsafe. Well it’s not, as evidenced in this case and our prior columns.
Some of our prior columns related to newborn
infant abductions:
December
20, 2011 “Infant Abduction”
September
4, 2012 “More Infant Abductions”
June
16, 2020 “Tracking
Technologies”
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”
References:
Segura
M. Baby found safe after being taken; Monroe, La.
hospital releases statement. KNOE News 2020; October 23, 2020
https://www.knoe.com/2020/10/23/missing-child-alert-issued-after-baby-taken-from-monroe-hospital/
Segura
M. Father of baby taken from Monroe hospital arrested. KNOE News 2020; October
26, 2020
https://www.knoe.com/2020/10/26/father-of-baby-taken-from-monroe-hospital-arrested/
Cole
C. St. Francis Medical Center shares infant security measures after baby was
taken from hospital. KNOE News 2020; October 26, 2020
Onken A, Gibson K. Newborn baby taken from Louisiana
hospital found safe. WALB News 2020; October 23, 2020
https://www.walb.com/2020/10/23/newborn-baby-taken-louisiana-hospital-found-safe/
KNOE
News Staff. Suspect accused of stealing baby turns herself in to police. KNOE
News 2016; updated April 25, 2016
RFT. SAFE
PLACE® Keeping Newborns Safe and Your Reputation Secure. RFT 2020; accessed October
29, 2020
https://www.rft.com/brands/safe-place/
NCMEC
(National Center for Missing & Exploited Children). Analysis of Infant
Abduction Trends. Data Collected: 1965 through September 2018. National Center
for Missing & Exploited Children 2018; Revised 09/15/2018
https://pnce.org/documents/57315-156_AdditionalResource.pdf
Miller
RS. Preventing infant abduction in the hospital, Nursing2007 2007; 37(10):
20,22
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