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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.
A second consideration is that such systems often rely upon Wi-Fi systems to broadcast the alarms and alerts to staff. Theoretically, an abductor could take advantage of malfunction of the Wi-Fi system to carry out an abduction. Hospitals doing a FMEA (failure mode and effects analysis) on risk of infant abduction or missing patient should ask what would happen if the Wi=Fi system happened to be down or whether someone could intentionally disable the Wi-Fi system.
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:
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%).
But NCMEC notes that not all infant abductor fit that profile. Only 7 of 325 infant abductors in the NCMEC analysis were male. The unique circumstance in this case (threat of potentially losing the infant to the Department of Children and Family Services likely had a role in the motivation for the abduction by the infant’s father.
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:
It also had recommendations to tell the parents:
The Miller article also had recommendations from a since-retired Joint Commission Sentinel Event Alert:
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.
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:
Segura M. Baby found safe after being taken; Monroe, La. hospital releases statement. KNOE News 2020; October 23, 2020
Segura M. Father of baby taken from Monroe hospital arrested. KNOE News 2020; October 26, 2020
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
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
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
Miller RS. Preventing infant abduction in the hospital, Nursing2007 2007; 37(10): 20,22
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