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Patient Safety Tip of the Week

September 20, 2022

More on Missing Patients



Our interest in missing patients was rekindled recently after a report that in two days two patients managed to leave the emergency department of an Illinois hospital and go missing (Graham 2022, NBC5 2022, Borcia 2022).  A 35-year-old patient was found safely and returned to the hospital, but a 61-year-old patient was found drowned in a nearby pond.


According to the news releases, the 61-year-old patient was being treated in the emergency department and left on foot before she was discharged. “There were concerns about the person’s mental state and sheriff’s deputies immediately attempted to locate her” according to the Sheriff’s Deputy. The sheriff’s canine “Duke” led deputies to a retention pond on the hospital property. A sheriff’s drone was deployed, and the drone pilot spotted the woman unresponsive in the water. Fire personnel were called to the scene and recovered the woman. They attempted resuscitation but she was pronounced deceased. Further details on these cases are not available.


Even without further details, there are several lessons learned here that need to be shared. First, while we often think about inpatient units and behavioral health units as sites most often impacted by wandering patients or patient elopements, the current incidents highlight the vulnerability of the emergency department.


Second, there were some new tools used in the above incident. We love the concept of using 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.


The search dog in the above incident used the scent of the patient to lead the search crew to the retention pond, where the victim had died. We don’t know whether the scent given to the dog was from something in the hospital or something the family brought from home.


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.


Fortunately, most eloping or wandering patients are found unharmed. But an incident like the one above is a reminder that there can be fatal outcomes in such cases. 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 (or abducted infants) need to be practiced at least annually and should also include your local law enforcement personnel.


If you identify a patient with confusion, dementia, hallucinations or frank psychosis in the ED, 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 you’d need to find a patient outside the facility. 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 Apple’s Air Tags, which use the wide network of iPhone users locate the device).


While a code for a missing patient should be announced over a PA system, some facilities have been reluctant to include a physical description of the missing patient over the air. 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 patient’s appearance may have changed since that photo was put in the EMR).


Our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients” described what should be done when a patient is missing:


The response to a missing patient is critical. It must be rapid, well-planned, and thorough 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 staff, 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.”


We also recommend you go back to our January 22, 2019 Patient Safety Tip of the Week “Wandering Patients” for many more details on what to do when a patient goes missing. In that column we also noted that Hattersley-Gray (Hattersley-Gray 2018) recommended placing some of the patient’s personal items and garments in a sealed plastic bag to help a search dog quickly identify the patient’s scent.


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.


While most of those recommendations from those previous columns are still appropriate, our current comments about the use of drones, search dogs, early involvement of police and family, and consideration of tracking devices for high-risk patients should be added to those recommendations.



See our previous columns on wandering, eloping, and missing patients:







Graham DT. Barrington-area hospital won't explain how 2 patients went missing in 2 days. Daily Herald 2022; July 22, 2022



NBC5. Two Patients Go Missing From Same Suburban Hospital, Investigation Underway. Two People Reported Missing From Suburban Hospital This Week, One Did Not Survive. 2022; Published July 20, 2022



Borcia S. Missing woman found dead in pond at Advocate Good Shepherd Hospital near Barrington. Lake and McHenry County Scanner 2022; July 19, 2022



Hattersley-Gray R. Responding to Elderly Patient Elopement and Wandering: Part 2. Campus Safety 2018; April 9, 2018



Hattersley-Gray R. Preventing Elderly Patient Wandering and Elopement: Part 1. Campus Safety 2018; March 15, 2018







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