Where's that baby? Kidnapping risk can be reduced with good policy

Success in past years obligates you to take right steps, or risk liability

Few messages are more chilling when they come over the hospital's public address system: A Code Pink is broadcast throughout the facility, and your heart immediately starts to race. Somewhere in the building, someone is trying to leave with a baby stolen from the nursery. Will they succeed?

The chances are slim if you've taken the right steps to thwart an infant abduction. If you haven't, the baby may be gone forever, and you will face one of the most devastating public relations disasters that can befall your facility, followed quickly by a massive lawsuit. Recent years have shown that certain steps are successful in preventing infant abductions and aiding in the recovery of stolen children, but that success means you are even more obligated than before to put the proper precautions in place. In addition to all the humanitarian reasons to protect babies, your hospital can face immense financial losses if parents show you ignored the steps proven to prevent such a tragedy.

Remember that an infant abduction is one of those highly emotional tragedies that will have far-reaching liability implications, says Sandy Mahon, vice president for risk management and quality assessment with Program Beta, the risk pool for hospital districts in California, based in Alamo. She coordinates risk management activities for 77 hospitals. A lot of money is at stake, but the losses will include more than finances.

"You can count on being sued after an incident like this. There's no doubt in my mind," Mahon says. "And it's a terrible financial exposure. Just huge. But an abduction also sends out very bad messages about other potential breaches in your clinical practices and professional responsibility. You can interpret the event as being a sign of major systems problems that the organization has throughout, and this just happened to be the event that identified you to the nation at large as a sloppy facility."

An infant abduction automatically qualifies as a sentinel event with the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), so it will spark a nightmare of investigations and reports. The adverse publicity from an infant abduction can have lasting implications for the health care facility, Mahon says. For years afterward, your hospital might be known as "the one where that baby was stolen." That, in turn, can affect revenues significantly if patients go elsewhere because they don't feel safe in your facility.

"Don't be surprised if everybody transfers their babies out of your pediatrics ward after an infant abduction," she says. "When you're a parent, and you hear that someone took an infant, that's understandable."

All facilities with infant admissions at risk

Information from the National Center for Missing and Exploited Children (NCMEC), which closely monitors infant abductions from health care facilities, indicates that the previous success of prevention efforts has increased the risk for hospitals that fail to enact them successfully. The hospital is more likely to be sued in cases where the abductor impersonated a hospital employee than in those cases in which the abductor used another method to obtain the child, the NCMEC reports. Lawsuits also have become more common in the 1990s than they were previously.

Mahon also suggests the risk may be growing for smaller facilities, as potential abductors see larger hospitals installing the more expensive security systems.

Infant abductions rank among those problems that are statistically unlikely to hit your facility, but the enormity of the tragedy makes it necessary to prepare for the possibility nonetheless. The best estimate for the frequency of infant abductions by nonfamily comes from the NCMEC, which says 12 to 18 infants are abducted from hospitals each year. If you add abductions by family members, usually when they hear the child will be turned over to child protective services, the number rises. The NCMEC reports that 88 infants were abducted from hospitals between 1983 and 1995. Five of them were never recovered. (The International Association for Healthcare Security and Safety, the professional group for hospital security directors, reports a slightly higher number of infant abductions that includes the last few years - 94 abductions from health care facilities since 1983.)

Infants can be abducted from any hospital or birthing facility, according to the NCMEC data. Eight percent of the abductions have occurred in facilities with no more than 200 beds, 45% in facilities with 201 to 400 beds, 21% in facilities with 401 to 600 beds, and 26% in facilities with more than 600 beds. Fortunately, 94% of the babies were located and safely returned within two weeks of the abduction.

Fifty-seven percent of the infants were taken from the mother's room, 15% from the nursery, 17% from the pediatric area, and 11% were taken while outside the hospital but still on hospital property. The NCMEC reports there has been no violence against mothers or health care providers in infant abductions from hospitals, but violence is common in abductions taking place outside the health care setting.

"The typical hospital abduction case involves an `unknown' abductor impersonating a nurse, hospital employee, volunteer, or relative in order to gain access to an infant," according to the NCMEC. An obstetrical unit, by its very nature, can be an easier place to abduct a child than its own home or a public place. The unit typically is busy with large numbers of staff, patients, visitors, family members, and volunteers. The short length of stay makes it hard for staff and patients to get to know each other, and a "stranger" is unlikely to be noticed.

Since most facilities encourage the mother to keep the child in the room for long periods, rather than in a possibly more secure nursery, an abductor only has to enter the room and devise a way to obtain the infant. Most hospital abductions involve mothers being conned into handing their infants to someone they believe is an employee.

"The vast majority of these women take on the role of a nurse and represent themselves as such to the mother and anyone else in the room with the mother," according to NCMEC education materials. "Once the abductor assumes this role, she asks to take the baby for tests, to be weighed, photographed, etc."

Abductors often visit more than one hospital or birthing facility in the community to assess the security and determine which ones have desirable infants. Some abductors target a specific infant and wait for an opportune moment to take the child, while others simply look for any infant and window of opportunity. Once the baby is snatched, the abductor usually leaves through a fire exit stairwell. The abductor may be visible in a hallway for as little as four seconds after taking the infant.

Remember that abductors sometimes stage a distraction in the hospital to help them escape with the baby. A fire in a closet or a loud argument in the waiting room may be a cover for an abductor. (See stories on pp. 82 and 87 for more details about infant abductions.)

Extensive prevention can diminish risk

Prevention programs have diminished the risk of infant abductions. The NCMEC reports that the number of abductions from hospitals in the United States dropped 55% in 1992, and by 1995 the number had dropped 82% from the 1983 figure.

That success rate puts an even greater obligation on health care facilities to take reasonable steps to prevent infant abductions, Mahon says. Particularly because the most effective steps - such as educating staff and parents - are not expensive or overly burdensome, the courts and government regulators will expect all facilities to take those steps.

"The suggested parts of an infant security program are relatively easy to put in place, and that would always work against you if you have to explain afterward why you didn't do it," Mahon says. "That will be used against you each and every time. If there are a number of recommended steps for addressing the exposure and you did nothing, you've breached your standard of care as defined by the industry and by a number of state regulations."

Put safeguards in place

There are many ways to prevent infant abductions and encourage recovery of the child. An overall hospital policy is necessary, and it should include emergency procedures to be enacted when the abduction is attempted. There also are technological solutions, including video surveillance and various types of sensors that can be placed on babies to set off alarms when they are carried out of a designated area. A number of procedural steps also should be put in place to minimize the chance of a successful abduction. (See infant security plan, inserted in this issue.)

Infant abduction drills are an option for testing the facility's precautions and helping familiarize staff with the proper procedures. Drills aren't used by all facilities, but they proved their worth in May when an infant was abducted from St. Edward Mercy Medical Center in Fort Smith, AR. Risk manager Eileen Kradel, RN, JD, tells Healthcare Risk Management the hospital's infant abduction drills helped staff react appropriately when the emergency was announced over the public address system. (See story on p. 82 for more on the abduction and how Kradel handled it.) The keystone of the hospital's policy calls for designated staff to cover certain exits in the hospital and watch for anyone carrying an infant.

"We were very satisfied with how everyone responded because we had made some changes in the policy, like adding new doorways to cover, but it all went off well," she says. "Even if people had questions about what to do, they were asking those questions as they moved toward the doorways. That kind of immediate response is very, very important."

Kradel runs an infant abduction drill once a year, using an actor to "abduct" a doll from the nursery and try to leave the hospital with it. The drills show weak points in the response plan and highlight problems, such as assignments not being passed on when staff change in a department.

In addition to the drills, Kradel's facility takes other precautions against infant abductions. Security cameras are placed throughout the neonatal unit, and parents are educated about the rules on who is allowed to take babies away from them. The infants are banded on the arms and leg, and the mother has a matching identification band. Fathers also are banded.

Drills can be important part of program

Abduction drills are not all that common among health care facilities, but they can be an effective way to educate staff, says Russell Jones, PhD, director of security and environmental services at Pennsylvania Hospital in Philadelphia and president of the International Association for Healthcare Security and Safety. Jones conducts occasional abduction drills at his own facility, which handles 5,000 births a year.

Jones cautions that abduction drills are just one component of an overall program for preventing and responding to infant abductions. No matter how useful, they will not be a complete solution. And the drills must be carefully controlled or they can turn into a problem themselves, he notes. The point of the drills should be educating the staff, not blaming them.

"The drills should not be designed to really come down on the negatives," Jones says. "The point is not to find out if Mary Jones did the wrong thing or to write somebody up. You want to use it as a learning experience, a way for people to walk through the process and see how everything is supposed to work."

Jones also believes in notifying the staff beforehand to minimize excitement and chaos; an infant abduction is so upsetting that the whole hospital can be thrown into an uproar just for the sake of a drill if the staff aren't notified first. Holidays are ideal times for drills because the patient load is minimal and there is ample downtime. The decreased staffing level during holidays also provides a worst-case scenario test for the hospital's procedures.

Although drills are a good addition to a prevention and response program, Jones and Mahon say experience has shown that education is by far the most important component. Staff must be educated, of course, but education of the parents also is crucial to help thwart abductions. All mothers admitted for a birth and parents with young children admitted for treatment should be briefed carefully. If they understand how to recognize legitimate employees, they may be able to identify an imposter who asks to take their babies, refuse the request, and summon help.

In addition to education, some high-tech precautions are necessary. How much depends on how many infants typically are in your facility, the perceived risk, and how much you can afford to spend. The most basic electronic precaution, and probably the most necessary, is a video surveillance system. Video surveillance probably is in use throughout your facility already as a general security precaution, but you may want to consider boosting its use in the nursery and pediatric areas. Cameras can be used to record images of people going through critical doorways, and they can be trained on babies considered especially high-risk, such as those in custody disputes.

Other high-tech solutions are available to activate an alarm if a baby is abducted. Some alarms are designed much like those commonly found in stores to defeat shoplifters, with small devices attached to the baby's identification bracelet or hidden in the diaper. Sensors stationed at nursery exits or stairwells detect the baby when it passes by, and an alarm sounds to alert the staff.

Such devices are a good idea if you can afford them, but Jones says they should not be considered absolutely necessary as long as you are following the policy and procedures that make up the more important parts of a prevention program. You probably can't afford a tagging system, he says, but that doesn't necessarily mean you're failing in your obligation to protect infants from abduction.

"The technology component, with the cameras and the tagging of babies and locking doors, is the bunker mentality," Jones says. "Unfortunately, a lot of hospitals have had to take that approach because of the risk, especially those with a high number of births. It's very difficult to secure a hospital completely, though, unlike a manufacturing facility where you can just lock the doors and not let anyone in."

Locked doors work, too

For some facilities, the infant alarm tags may be impractical anyway, notes Joy L. Wyler, MT, JD, director of legal affairs and risk management at Children's Mercy Hospital in Kansas City, MO. At a children's hospital like her own, alarm tags would not work the way they do in a hospital that has almost all its children in the delivery area or on a single pediatric ward. With a hospital full of infants and children, the alarm tags would serve a limited purpose.

"We'd end up tagging all of our patients, and since they move all over the hospital for legitimate reasons, the only place we could put the alarm sensor is on the exit doors," Wyler says. "If that's the first time the alarm goes off, it would be hard to retrieve the child or identify who took the child."

Wyler's facility compensates for that dilemma by locking down the facility more than many hospitals might find necessary. Every patient care area in the children's hospital has locked entrances. Employees must use an identification and access card, while visitors can buzz a staff member to request entrance. That allows staff to monitor who enters children's areas.

Harden your facility's defenses

When designing a program to prevent infant abductions, Jones suggests keeping in mind that you want to make your facility a "hard target" for abductions. It may be impossible to completely prevent an abduction, but you want to make the potential abductor think of your facility as a place where the abduction will be a real challenge. Research has shown that abductors often visit several facilities in the community to assess the security and learn the daily routine with infants.

Once the staff report an abduction, everything hinges on a quick response. The facility's response plan should include having staff rush to all possible hospital exits immediately to stop the abductor or at least get a description of the person. That can greatly aid in the recovery of the child.

And the response should include the local news media as much as possible. Unlike many other crises at your facility, this is one situation where news reporters are your best friends. You'll need to coordinate the release of any information with the law enforcement authorities investigating the abduction, but they will be eager to involve the media as well. Abducted infants almost always are recovered through the efforts of local media publicizing the infant abduction, along with a description of the baby and the abductor. The story always is a sensational heartbreaker that the media are eager to cover, so be sure to use that to your advantage.

"You absolutely want to involve the media, and do it quickly," Jones says. "They are your best ally in this situation. They are going to be the ones that get the baby recovered, hands down."