Infant Abductions: Preventing Future Occurrences

Since the Joint Commission began tracking sentinel events three years

The National Center for Missing & Exploited Children in Arlington, VA, reports that there have been 104 infant abduction cases in health care facilities from 1983 to 1998. Ninety-eight of the infants were located, while six are still missing. In the 13 cases reported from 1996 to 1998, one of the infants is still missing. Between 1991and 1998, there was a 55 percent reduction in infant abductions from health care facilities.

ago, the Accreditation Committee of the Joint Commission's Board of Commissioners has reviewed eight cases related to infant abductions. For each of the events reviewed, a root cause analysis was completed.

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 was in the neonatal intensive care unit. Seven of the infants 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 cases, a woman pretended to be a volunteer, physician or the infant's mother. In one of the cases, the birth mother abducted a child that was in the state's custody from a neonatal intensive care unit. Despite these different circumstances, the root causes identified below provide advice that could reduce risk in any infant abduction situation.

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, the abduction took place during the day shift. The abduction occurred during the evening shift in two cases and during the night shift in two cases.

Root Causes Identified

All the hospitals identified unmonitored elevator or stairwell access to the postpartum and nursery areas as a root cause. Root causes fell into the following six general areas:

• Security equipment factors such as security equipment not being available, operational or used as intended.
• Physical environmental factors such as no line-of sight to entry points as well as unmonitored elevator or stairwell access.
  Inadequate patient education.
• Staff-related factors such as insufficient orientation/training, competency/credentialing issues and insufficient staffing levels.
• 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.
• Organization cultural factors such as reluctance to confront unidentified visitors/providers.

Suggested Strategies for Reducing Risk

The Joint Commission suggests that hospitals consider the following actions:

• Develop and implement a proactive infant abduction prevention plan.
• Include information on visitor/provider identification as well as identification of potential abductors/abduction situations (during staff orientation and in-service curriculum 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 baby's physical examination within two hours of birth.
• Require staff to wear up-to-date, conspicuous, color photograph identification badges.
• Discontinue publication of birth notices in local newspapers.
  Consider options for controlling access to 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.

Experts' Recommendations

The Joint Commission's Standard EC.1.4 in the Comprehensive

Experts identify the following as the three key steps to preventing infant abductions. Educating staff   Educating mothers   Access control

Accreditation Manual for Hospitals: The Official Handbook, calls for a management plan to address security and includes as an example of implementation a community hospital's study of security in its postpartum newborn nursery area. The National Center for Missing & Exploited Children in Arlington, VA, has published guidelines that are intended to provide, in part, security strategies and protocols that support and enhance the Joint Commission's standards on security issues. For a free copy, call the National Center at (800) THE-LOST.

Educating staff, educating mothers and access control are the three key steps to preventing abductions, according to experts. Russell L. Colling, a health care security consultant in Salida, CO, says nurses need to be aware of visitors who are frequently coming to the nursery and postpartum areas, since new mothers are usually hospitalized for only one or two days. He recommends that nurses introduce themselves to visitors if they don't know them and be assertive when seeing strangers in corridors. "Nurses must accept ownership past that of clinical care," he says.

As for educating mothers, the organization should tell mothers which staff members they can release their baby to and then have the mothers sign a form to acknowledge that the hospital provided this information. The experts recommend that staff who are allowed to take babies from mothers or the nursery wear a highly visible photograph identification badge. "This becomes a baby O.K. hall pass," says John B. Rabun, Jr., vice president and chief operating officer for the National Center for Missing and Exploited Children. Colling has seen hospitals use clever informational reminders such as placing stickers on bathroom doors or tent cards on tables in the postpartum room.

In addressing access control, Rabun recommends that the hospital form an interdisciplinary team of staff from nursing, risk management and security to determine how to secure entry points, including access to doors for visitors and staff. Colling says the hospital should use a designated public entry point and restrict access to all other entry points. Large units can have a secondary entry point, but at that entrance there should be a closed-circuit television system with a videotape record.