Patient Safety Tip of the Week

October 15, 2013     Missing Patients



There’s been considerable interest in how to deal with missing patients in view of the recent news of a missing patient found dead at San Francisco General Hospital (Ho 2013). For those of you not familiar with that case, a 57 y.o. female inpatient on a med-surg unit went missing from the hospital on September 29 and she was found dead in a stairwell at the same facility 17 days later. Findings of both the internal root cause analysis and the external investigation are not yet known. Nevertheless, this incident at a hospital known for its high level of commitment to patient safety should make everyone say “could that happen here?”.


When that news broke we went back and reviewed our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients”. We think the advice and recommendations in that column remain so relevant that we’ve decided to print it again in its entirety below.


There are a couple other useful resources pertaining to missing patients that have become available since our earlier column. One is a directive in the VA system regarding management of wandering and missing patients (VHA 2010). The VHA directive includes recommendations about assessing all patients for risk of wandering or becoming missing while in treatment. It then describes what should be done when a patient is found to be missing, including both preliminary and full searches. It discusses designation of persons to be responsible for various aspects of the response to a missing patient, including “off-hours” as well as during usual business hours. Particularly useful is the discussion of the full search. This includes superimposing a grid map over a site and facility plot to delineate the search sectors. One individual is assigned responsibility to ensure all search grid sector assignments are made, the times and by whom grid sectors are searched, times and by whom each building is searched, times and to whom notifications and requests are made, and results of the searches. The recommendations include a description of both the indoor search and the outdoor search. It describes that each search team has a leader and how members of the search teams are to conduct their searches.


Obviously, all staff must have a thorough understanding of what to do during a search. This can be done through orientation, competency assessments, and regular drills.


One particularly good piece of advice from the VHA directive is to ensure that someone from the hospital is assigned the responsibility of regular contact and followup with the missing patient’s family and friends.


Another good piece of advice comes from the Minnesota Hospital Association (MHA 2011). Most of you are aware of the movement to replace “codes” with plain language for paging emergencies in hospitals (and other healthcare settings). In our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients” we noted your “code” should be announced with a brief description of the missing patient (age, sex, race, unit, etc.). The MHA recommends that the plain language overhead page be: “Missing person (of any age) + descriptor (and as appropriate, action for staff/patient/visitors.)” We think that including something about the action to take is important for both staff and visitors.


Also, you may want to note that we’ve done several columns pointing out the role of smoking in patient elopements (see our December 2012 What’s New in the Patient Safety World column “Just Went to Have a Smoke” and our April 2, 2013 Patient Safety Tip of the Week Absconding from Behavioral Health Services”).


One other point not included in either our prior column nor the VHA directive is that all surveillance cameras should be accessed to see if the missing patient can be seen. This would include not only any internal security cameras at your facility but also any external security cameras (parking lots, etc.). You might also consider security cameras that might be available at neighboring stores, service stations, etc.



Update: Please also see our December 2013 What’s New in the Patient Safety World column “Lessons from the SFGH Missing Patient Incident” and our April 7, 2015 Patient Safety Tip of the Week “Missing Patients and Death”.



Here is our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients”:


July 28, 2009              Wandering, Elopements, and Missing Patients


The May 25, 2009 issue of Inside the Joint Commission Online has several articles dealing with wandering, elopements and missing patients. The issue was apparently triggered by an unfortunate sentinel event in Pittsburgh in which an elderly woman with dementia wandered onto a roof and froze to death. All types of facilities need to develop policies and procedures for:

1)      doing an assessment for risk of wandering or elopement

2)      implementing risk reduction strategies for those patients at risk

3)      performing a prompt and thorough search when a patient is missing


Many of the risk factors for wandering and elopement are also risk factors for delirium. So if you have been following this column and begun screening for delirium risk factors, you are halfway there! Alzheimer’s disease or any dementia may predispose the patient to wandering. Most of you recognize the term “sundowning” which we apply to those patients with dementia who become more confused and disoriented in new unfamiliar settings such as the hospital. Such patients may be prone to wandering and elopement. But any patient with impaired cognition may be at risk. This includes patients with psychiatric disorders, developmental disabilities, and acquired neurological disorders.  But there are other risk factors or contributing factors as well. Many of the drugs we’ve talked about under delirium (particularly sedating agents) may contribute. A prior history of wandering or elopement (eg. at a long-term care facility prior to admission) should be a red flag.


Some standardized questions that appear on most wandering assessment tools are:


Others have emphasize “exit-seeking behavior” such as talking about going home or asking about things not available on the unit (typically something such as candy bars).


Just as with fall risk assessments or delirium risk assessments or even DVT risk assessments, things change during a hospitalization. Therefore, a single assessment for elopement risk on admission is not sufficient. That risk assessment must be repeated after surgery, at internal transfers of care, and any time there has been a significant change in the patient’s mental status or overall medical status. The same patients should have formal risk assessments for delirium and falls.


So what do you do when you identify a patient as being at-risk for wandering or elopement? It makes sense to put them in a room where staff would be more likely to see them exit the room (usually closer to the nurse’s station). Many floors have one or two rooms that are video monitored, a logical choice for such patients. Consider having the patient wear a gown that is a different color than the usual gowns so that all staff would recognize such patient as being “lost” if encountered in other parts of the hospital. Potential exit doors on the unit should be fitted with appropriate alarms (that are functioning correctly) and with appropriate signage to keep the door closed. Consider keeping the patient in a room with a roommate or have family members stay in the room. Attention to the patient’s physical needs (food, water, warmth, pain management, toileting) are important. Letting the patient walk or exercise under supervision may be useful. The references below (AHRQ Web M&M, Veteran’s Administration Wandering Resources, Spencer 2008, Evidence-based guideline: Wandering) all contain excellent points on care management of the patient at risk for wandering.


Internal patient transports may also be vulnerable events. You’ve heard us talk on several occasions about the “Ticket to Ride” concept in which a formal checklist is completed for all transports (eg. to radiology). Such checklists typically contain information related to adequacy of any oxygen supplies and medications needed but should also include information about things like suicide risk and elopement risk. These all need to be conveyed to the caregiver who may be accepting the patient in the new area. Just as we’ve talked about cases where a patient may attempt suicide in a bathroom in the radiology suite that is not suicide-proofed, a patient at risk for elopement may wander off easily while waiting in the radiology suite if not appropriately supervised.


The response to a missing patient is critical. It must be rapid, well-planned, and thorough in order to find the patient before he/she suffers any harm. Some facilities have chosen to merge their infant abduction policy with the elopement or missing patient policy since the procedures may be very similar. But be careful – you don’t want your staff searching for a newborn by mistake when they should be looking for a wandering geriatric patient.


Staff on the unit need to be notified as soon as a patient is missing. A very brief head count of patients and look in 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.). 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). 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.


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 (don’t forget to include them in your planning process). Many facilities also use many 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 saff, describing the missing patient and including a photograph if one is present on the information system. The patient’s 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.


What do you do when you find the patient? First, be aware they are likely confused and be careful not to frighten them. Do a brief assessment as to whether they may have been injured. Notify the command center you have found the patient and either return them to their unit or to the emergency department. They should be evaluated by a physician at that time to determine whether any injuries have occurred. In the unfortunate circumstance where the patient is found dead, the scene should be left undisturbed because the authorities will treat it as a crime scene.


Drills are critical for any event that is likely to be rare but critical when it occurs. Just as we’ve hammered home in our discussions about surgical fires, it is important that all staff know what to do during certain emergencies and the best way to prepare for those is with drills. Yes, you can and should include education and training on missing patient alerts during orientation and annual reorientation but you have to periodically run a drill to see whether the responses are adequate and timely. During drills one may also see various nooks and crannies and other areas (eg. ventilation ducts) that a patient could get into, perhaps leading to some physical improvements to prevent such dangerous access. You might also consider using a “secret wanderer” (person dressed as a patient in one of the special colored gowns) to see if staff identify them as a wanderer.


Staff education obviously is important but should be ongoing rather than just being delivered at annual orientation sessions. The Bay Pines (Florida) VA Hospital uses a creative reminder device on patient care areas that is shaped like a stop sign and uses the mnemonic “DON’T GET LOST” which stands for:


            D         Determine at-risk patients

            O         Observe for wandering triggers

            N         No-fall environment

            T          Teach staff/nonclinical support


            G         Get patient involved in activities

            E          Exit control

            T          Talk to patient and provide reassurance


            L          Low patient to staff ration

            O         Offer food, drink and toileting

            S          Structure and routine

            T          TEAMWORK!!


Ongoing surveillance is also important. When we do patient safety walkrounds we also incorporate much of what traditionally has been termed environment of care rounds. We look to see that doors and other accesses to dangerous places are locked and appropriately alarmed. We also look at windows leading to rooftops and make sure no one could open them and exit onto a rooftop.


How can technology be utilized to minimize the risk of elopement? There are several technology devices that can be used to alert staff when at-risk patients are leaving their bed or their area of care and others that can be used to track and locate such patients. All agree that such systems should never be relied on as the sole means of monitoring such patients. And each day the system/device should be checked to ensure it is functioning properly.


In addition, our electronic medical records (EMR’s) and clinical decision support tools can be used to help identify at-risk patients and flag them as being at-risk. For instance, if a patient has wandering during one hospitalization (or wandering during a LTC stay), his medical record can have a flag set that identifies him as at risk for wandering during future admissions.


You probably will be unable to prevent every potential elopement. When one does occur, do a debriefing session as soon as possible to identify potential missed clues and other useful lessons. Then do a formal root cause analysis within a short timeframe. There are always valuable lessons learned that hopefully can prevent other elopements in the future.







Elopement. Inside the Joint Commission Online 2009; 15:4-8. May 25, 2009.



Gerardi D. AHRQ Web M&M Case. Elopement. December 2007



Veterans’Administration. Wandering Resources.,d.dmg



National Guideline Clearinghouse. Evidence-Based Guideline: Wandering.



Spencer E. Policy for Assessment and Care Management of Patients who are at risk of Wandering in the Acute Care Setting. University Hospitals of Leicester. August 2008



Print “Wandering, Elopements, and Missing Patients






Additional references:



Ho V. Body in SF General stairwell IDd as missing patient. San Francisco Chronicle 2013; Updated 10:46 pm, Wednesday, October 9, 2013



Department of Veterans Affairs. Veterans Health Administration (VHA). VHA Directive 2010-052. MANAGEMENT OF WANDERING AND MISSING PATIENTS. VHA 2010; December 3, 2010



Minnesota Hospital Association (MHA). Plain Language Overhead Emergency Paging. Implementation Toolkit. 2011








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