JCAHO issues advice on infant abductions
Eight cases analyzed in sentinel event review
The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, has completed its analysis of eight infant abduction cases and is now offering the latest advice on how to prevent these devastating crimes.
The Joint Commission began tracking sentinel events three years ago. Infant abductions automatically are considered sentinel events, so each of the eight events was followed by a comprehensive review of the systems and procedures that may have allowed the incident. The Joint Commission’s review included the root cause analysis the health care provider completed in each case.
Most at risk: Larger hospitals
Here is some of the information and advice gleaned from those analyses:
• All of the abductions took place in hospitals with more than 400 beds.
• Five of the events occurred in the mother’s room, while two were in the newborn nursery, and one took place in the neonatal intensive care unit.
• Seven of the infants later were recovered unharmed, most within a few hours, and there was no evidence of violence to the mother or child. One of the infants is still missing.
• All of the abductors were female. In three of the cases, a woman impersonated a nurse or aide. In the other abductions, a woman pretended to be a volunteer, a physician, or the infant’s mother. In one of the cases, the birth mother abducted a child who had been placed in the state’s custody from a neonatal intensive care unit.
• Infants were abducted when taken for testing, during return to the nursery, when left unattended in the nursery, or while a mother was napping or showering.
• Three of the eight hospitals reported the discovery of failed abduction attempts shortly before the abduction occurred.
• In four cases, abductions took place during the day shift. Abductions occurred during the evening shift in two cases and during the night shift in two cases.
The Joint Commission’s sentinel event investigation requires the provider to determine the root causes of the event. In the infant abduction cases, the root causes were similar. All the hospitals identified unmonitored elevator or stairwell access to the postpartum and nursery areas as a root cause.
Other root causes fell into the following six general areas:
1. security equipment problems, such as security equipment not being available, operational, or used as intended;
2. physical environmental problems, such as no line-of-sight to entry points as well as unmonitored elevator or stairwell access;
3. inadequate patient education;
4. staff-related problems such as insufficient orientation/training, competency/credentialing issues, and insufficient staffing levels;
5. information-related factors such as birth information published in local newspapers, delay in notifying security when an abduction was suspected, improper communication of relevant information among caregivers, and improper communication between hospital units;
6. organizational culture factors such as reluctance to confront unidentified visitors and providers.
Strategies to prevent abductions
In consideration of those causes, the Joint Commission suggests that hospitals take these preventive steps:
• Develop and implement a proactive infant abduction prevention plan.
• Include information on visitor and provider identification as well as identification of potential abductors/abduction situations during employee orientation and inservice programs.
• Enhance parent education concerning abduction risks and parent responsibility for reducing risk and then assess the parents’ level of understanding.
• Attach secure identically numbered bands to the baby (wrist and ankle bands), mother, and father, or significant other immediately after birth.
• Footprint the baby, take a color photograph of the baby, and record the results of the baby’s physical examination within two hours of birth.
• Require employees to wear up-to-date, conspicuous, color photograph identification badges.
• Discontinue publication of birth notices in local newspapers.
• Consider options for controlling access to the nursery/postpartum unit such as swipe-card locks, keypad locks, entry point alarms, or video surveillance (any locking systems must comply with fire codes).
• Consider implementing an infant security tag or abduction alarm system.
(Editor’s note: For more on strategies to prevent infant abductions in your facility, see Healthcare Risk Management, July 1998, pp. 77-87.)
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