Prevent infant abductions with FMEA processes

Identify key areas of concern

Do you think that a kidnapper could walk undetected through the halls of your hospital by using a fake ID badge and get away with a baby? That’s exactly what happened at one Salt Lake City facility, when a woman wearing hospital scrubs and a makeshift badge managed to abduct a 3-day-old infant. The baby was returned to the mother within 30 minutes of the abduction, after a security guard found the kidnapper in a grocery store a block away.

This frightening incident puts a spotlight on the need for effective policies to prevent infant abductions. A total of 18 infant abductions have been reported since the Joint Commission on Accreditation of Healthcare Organizations began tracking sentinel events in January 1995.

Quality managers at Good Samaritan Hospital in Puyallup, WA, met for a brainstorming session of worst-case scenarios that could occur. "We looked at our hospital very carefully to determine the most dreadful things that could happen," says Jann Robinson, RN, MA, CPHQ, the organization’s patient safety officer. "Infant abduction was at the top of the list."

The decision was made to do a failure mode and effect analysis (FMEA) on infant abduction. "We determined that this was an extreme patient safety risk and the most devastating thing that could happen at our facility," says Robinson. Here are steps being taken as part of the organization’s FMEA, which currently is under way:

• An infant abduction FMEA team was formed.

First, the team created a flowchart to identify every possible failure mode. "The goal is to flow chart the system as it is working today in our hospital, then go through each one of those points and identify what could break down," Robinson says. For example, a receptionist giving access to a visitor without following procedure would constitute one type of failure mode.

As different categories are identified, smaller teams are being formed from appropriate areas, which will report to the FMEA team, she says.

For example, a team made up of facilities and security staff and a representative from the alarm company would address the alarm system itself, or a team with staff from education, patient safety, nursing, and security would be asked to formulate an education plan.

The stakeholders currently included in the process are obstetrics, security, patient safety, and the nursery, reports Karen Baker, manager of the obstetrics unit. "Our plan is to bring in additional stakeholders as appropriate."

• Key areas of concern were identified.

These possible failure modes were identified:

— Access to the unit, including hospital personnel, visitors, and construction.

— Interface with door closure. "The current security system that we have interfaces with our door access system," says Baker. "We will address the mechanical interface integrity, global lockdown, and fire alarms/door egress."

— Alarm issues such as false alarms, response to alarms, consistency in staff response, and transmitter errors.

— Prevention, including drills, education, orientation, annual review, and patient/visitor education.

— The hospital’s "Code Pink" response for infant abduction, including drills, policy review and update, and staff education.

• Preliminary changes were identified.

So far, a long list of possible changes have been identified, Baker says. These include implementing an improved system to control visitors; redirecting access to the unit through the service corridor; limiting the number of doors into the unit; requiring training for all construction workers; doing an education blitz for patients and staff; creating a structured preventive maintenance plan; and documenting and archiving all debriefings following drills.

"I know as we work through the FMEA, we will identify many other issues and processes that will need to be addressed," she adds.

• Access is limited.

It was discovered staff were taking a potentially risky shortcut using the main doorway instead of the service entrance. "They would get their cart through and keep going without checking to see that no one else came in behind them," Robinson adds. Staff now are required to use the mirrored service entrance, which enables staff to check that no one is following, at which point they enter the labor and delivery area through a second door. Although nurses and receptionists have been taught proper procedure for visitors, there has been inconsistent adherence to this process, she says.

The current procedure is to stop each visitor, ascertain who he or she is visiting requiring first and last name, and identify support people who are wearing an identification wristband. At the point of entry to the unit, visitors are given a detailed explanation for the policy and requested not to hold the door for any other individuals, either staff or visitors. Once they are on the unit, the visitor is to proceed directly to the patient’s room. "We don’t know exactly what avenue we are going to be taking, but we are going to do something to have accountability for visitors," says Robinson. "We suspect we are going to badge people or give wrist bands such as "Dad" or "Significant Other," or give patients cards to hand out to a limited number of visitors."

• A mock "infant abduction drill" is done at least twice a year.

To test whether staff were searching bags appropriately, Maureen Guzman, RN, MHA, CPHQ, director of quality management, has begun conducting mock infant abduction drills. "I had a pretend baby in my bag, and I got completely out of the hospital. We found that people at our facility are so nice that they don’t want to stop somebody and ask What is in your bag?’"

If a staff member manages to stop the mock abduction, a $55 gourmet gift basket is given as a reward. However, with three drills to date, no one has ever stopped the abduction, reports Robinson. During one drill, she noticed staff were hesitant to stop anybody who had on a hospital badge. "We’ve done a lot of training around this; I don’t care who they are, an employee or the president, you stop them."

• Each unit was inserviced.

Previously, the infant abduction policy was sent out and nurse managers explained it to staff, but this obviously was not effective since staff aren’t consistently following procedures, adds Robinson. Now, each hospital employee attends orientation and an annual update where the infant abduction policy is reviewed. "However, we continue to have gaps in the responses by staff during infant abduction drills," she says.

The plan is to have an "infant abduction month" when posters will be hung throughout the facility, including the policy, profile of a typical kidnapper, and staff responsibilities. "Poster design will be attention grabbing but still project the severity of this issue," Robinson points out. Also, a team will go to each unit to educate staff about the policy. For example, when staff complained about wheeling carts the extra few steps to the service entrance door, quality managers pointed to real-life infant abduction cases to bring home the seriousness of the problem. "Sometimes, people don’t think of the reality of what could happen," she says. "A few cases have been very notorious in the media. We used these to give people a mental image of what could happen."

[For more on preventing infant abductions, contact:

Karen Baker, Manager, Obstetrics Unit, Good Samaritan Hospital, 407 14th Ave. S.E., Puyallup, WA 98371-0192. E-mail:

Jann Robinson, RN, MA, CPHQ, Patient Safety Officer, Good Samaritan Hospital, 407 14th Ave. S.E., Puyallup, WA 98371-0192. Phone: (253) 697-1962. Ext. 1962. E-mail:

A book and self-assessment tool are available on the National Center for Missing & Exploited Children’s web site at Click on "Media," "Publications," "For Healthcare Professionals: Guidelines on Prevention of and Response to Infant Abductions." The first 10 printed copies are free of charge for facilities. To order, contact: National Center for Missing & Exploited Children, Charles B. Wang International Children’s Building, 699 Prince St., Alexandria, VA 22314-3175. Phone: (800) 843-5678 or (703) 274-3900. Fax: (703) 274-2200.]