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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.
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.
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:
- 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:
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. NBCChicago.com 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
https://www.campussafetymagazine.com/news/elderly-patient-elopement-wandering/
Hattersley-Gray R. Preventing Elderly Patient Wandering and Elopement: Part 1. Campus Safety 2018; March 15, 2018
https://www.campussafetymagazine.com/hospital/elderly-patient-wandering-elopement/
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