Armed Forces Institute of Pathology
Continuing Nursing Education Online
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By Elizabeth A. Mittelstaedt,
Lieutenant Colonel, U.S. Army Nurse Corps & At approximately 1:30 A.M. on a Saturday morning, a woman entered a hospital through a busy emergency room. She put on a lab coat and stethoscope and identified herself to the hospital staff as a physician from a nearby hospital. Subsequently, she entered a patient’s room, took the patient's newborn baby, placed the baby in a bassinet, pushed the bassinet down a 50-foot hallway, and escaped through an exit. The security cameras were not working at the time. As a result of a media blitz, a store employee identified the woman when she attempted to steal baby clothes and notified the authorities. Nineteen hours later the baby was found in a cardboard box behind a grocery store. The woman was charged with second-degree kidnapping, burglary, and criminal mistreatment. The hospital was sued and settled out of court for an undisclosed amount.1, 2, 3
Introduction The abduction of an infant is a devastating event that poses significant legal and financial risks to health care facilities and providers. Abduction, defined as the forcing of a victim to accompany an offender to a different location,4 is a crime punishable by civil and criminal penalties.5 Though not a crime of epidemic proportions, the abduction of infants from health care facilities has clearly become a subject of concern for parents, health care providers, hospital administration, law enforcement officials, and the National Center for Missing & Exploited Children (NCMEC).6 Historically, hospitals were considered sanctuaries for healing and inviolate environments.7 Recently, however, hospitals have become the primary target for infant abductions.8 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) characterizes an infant abduction from a health care setting as a sentinel event. A sentinel event is defined as the risk of, or the unexpected occurrence of, death or serious physical or psychological injury.9 Scope of the Problem "During the time a child is growing up, predators will attempt to abduct more than 2.6 million children. In almost 100,000 cases, they will be successful. Of these, 10,000 kids will never be seen again, and 4,000 will be murdered."10 In one study of 655 cases, 74% of the children were murdered within three hours.11 In one major study of 145 infant abductions, 83 infants were taken from hospitals. Of these, 49 infants were taken from the mothers' rooms, 14 from nurseries, 13 from pediatric hospital rooms, and 7 from various other locations within the hospital.12 In another study of eight infant abductions that occurred in hospitals with more than 400 beds, five occurred from the mothers' rooms, two from newborn nurseries, and one from a neonatal intensive care unit. All eight of the abductors were female. One of the abductors was the birth mother of an infant under state custody, three impersonated nurses or aides, and four pretended to be volunteers, physicians, or the infants' mothers. Scenarios used to abduct the infants included: 1) taking the babies from the mothers "for tests", 2) intercepting the infants during return to the nurseries, 3) removing infants from the nurseries when unattended, and 4) entering the mothers' rooms during their naps or showers. Four abductions occurred during the day shift, two during the evening shift, and two on the night shift. Three of the eight hospitals had experienced previous abduction attempts.13 Abductor Profiling
According to the NCMEC, infant abductors are usually familiar with the layout of the targeted hospital through prior visits. They are most often women of childbearing age, are usually infertile or seeking to replace lost children, and frequently mislead their family and friends into believing that they are pregnant. To help maintain this fiction, they tend to be overweight or dressed in maternity clothes, and eventually feel compelled to produce a baby. 14, 15
Emotional Impact of Infant Abduction on Family Members The impact of infant abductions on family members is usually devastating. Burgess described the sudden, unexpected loss of an infant followed by an indefinite period of uncertainty regarding the child's well-being as a traumatic family crisis. She interviewed 38 family members of abducted infants. Sixty-eight percent believed their life goals had significantly changed, 71% of the mothers stopped work to stay home with their children, and 87% increased positive interactions with their children. The most significant finding of all, however, was that 90% instituted firmer family structures, rules, heightened supervision, and accountability. Further, Burgess identified several stages where symptoms similar to those associated with Post Traumatic Stress Disorders could occur. The stages she identified included the first stage when the news of the abduction was received, the second stage during the period while the infant remained missing, the stage of infant recovery, the stage of rebonding between the infant and the parents, the stage of litigation and prosecution of the abductor, and the stage of retraumatization. The symptoms seen in the family members of abducted babies included intrusive images of the infant being sold, abused, neglected, hurt, and discarded, changes in appetite, increased nervousness, sleep disturbances, and nightmares.16 Professional and Legal Responsibilities Hospitals and health care providers have a legal duty to use reasonable care in protecting and preventing foreseeable injury to their patients and third parties. Negligence in providing for patient safety may potentially result in large damage awards and even threaten a hospital's Medicare participation, as recently happened to a Chicago hospital after an infant was abducted from its nursery and later found outside the facility.17 Additionally, JCAHO accreditation standards specifically require security plans for safeguarding infants. As long as security plans are deemed adequate, the specifics are left to the facility. When a sentinel event like infant abduction occurs, a medical facility may voluntarily report it to JCAHO. However, once the incident is disclosed, regardless of source, a thorough and credible root cause analysis and action plan must be prepared and submitted to JCAHO within 45 calendar days of JCAHO learning of the event.18, 19 Documentation regarding an abduction should be brief, factual, specific to each facility and included on both the mother's and infant’s chart. Documentation should include the date and time the infant was found missing and indicate that the infant security protocol was initiated. An incident report should be completed with all relevant information. In some states, and in most federal facilities, an incident report is considered a protected quality assurance document exempt from discovery and introduction as evidence. In other states, however, it is treated the same as any other business record, and whatever is written therein may be used at trial or in disciplinary proceedings or state administrative actions. Therefore, either the hospital's or an individual's defense or liability may depend on its contents. Developing an Infant Security System As part of the accreditation process by the JCAHO, the maternal child health section of a military medical center formed a multidisciplinary team to develop a plan for infant security. Initially, a literature review was completed and three commercial infant security systems ranging from $20,000 to $100,000 were evaluated. Ultimately, a customized system, consisting of a color-coded electronic badge and card-swipe system, strategically located surveillance cameras and devices was developed. In addition, all entrance and exit doors of the labor and delivery, NICU, the mother-baby, antepartum, and gynecology units were locked and monitored. New policies and procedures based upon NCMEC's recommendations were developed and implemented.20 Finally, specific educational classes and in-services regarding the new infant security system were provided to both staff and patients. Planning A Mock Infant Abduction Drill To evaluate staff knowledge and the effectiveness of the new infant security system, a mock infant abduction exercise was planned with several broad objectives. The objectives were to 1) have the staff systematically search the unit for the infant, 2) notify hospital security and other key personnel immediately, and 3) intercept or obtain the description of the mock abductor, preferably before contact with an infant was established. A realistic scenario was devised and key participants including a volunteer patient and a mock abductor were selected to participate. The drill was purposefully scheduled during change of shift since this offered a relatively distracting time similar to what might tempt an abductor. The exercise was to be terminated if a staff member detained the mock abductor to check her credentials, or the infant's mother requested that the drill be stopped, or the staff had an unusual adverse reaction to the exercise. Key hospital personnel were briefed on the salient aspects of the drill. Conducting a Mock Infant Abduction Drill The number of patients and their acuity levels were unusually high on the day of the abduction drill. Eight regular and augmenting staff members, three students, and one instructor were present on the unit. As planned, the mock abductor, using an improper color-coded identification badge containing someone else's picture, arrived on the unit during morning report, walked around the nurses’ station, and read the census board without being confronted. Next, she entered the participating mother’s room. She then returned to the nurses’ station to give the staff another opportunity to stop her, but as before, she was not challenged. The mock abductor returned to the mother’s room, placed a "mock infant" of shaped towels with a baby's cap in a bassinet, pushed the bassinet past the nurses’ station and down the hall, exited the secured doors as another individual was entering, and left the bassinet with the mock infant just outside the unit. Shortly thereafter, the mother approached the nurses’ station and asked the staff the whereabouts of her baby. She explained that a female in a white lab coat came into her room and took the infant for a test. The staff, realizing that no tests were ordered for the infant, asked for a description of the female, notified hospital security and the nursing supervisor, and initiated a desperate search of the area. Some staff were actually running down stairwells completely convinced that a real baby abduction had taken place. A staff nurse subsequently found the bassinet with the "mock infant" a short distance outside the unit. The exercise was concluded, and a computer message regarding the completion of the exercise was sent to all key personnel. Drill Evaluation A debriefing immediately followed. Discussions included the pros and cons of the actions of the abductor and the staff. Most of the staff members were visibly upset by the exercise. Some cried, some were silent, while others were very talkative. All acknowledged that the drill had been very realistic and were very concerned that an infant could actually be taken off the unit. The overall exercise was deemed a success because staff awareness of infant security was greatly enhanced. The hospital chaplain and psychiatric clinical nurse specialist were called in to provide counseling as needed to the staff. A second test of our infant security system came during the next JCAHO survey when the nurse inspector entered a mother’s room and attempted to remove her baby by asking the mother if she could take the infant for care. The mother responded immediately with, "No, you do not have the right color on your badge!" and the father escorted the inspector to the nurses’ station for further identification. The hospital received a perfect score of 100% with specific mention by the inspector of her inability to remove an infant from a patient’s room. Lessons Learned Table 1 summarizes the lessons learned from this mock infant abduction exercise, as well as some of NCMEC's recommendations for prevention of and response to infant abductions.
Summary An infant abduction is a JCAHO sentinel event and death is an all-too-frequent outcome. It is emotionally painful to both families and staff. An infant abduction may be financially costly to hospitals and negligent staff members as well. Hospitals and health care providers have a legal duty to use reasonable care in protecting and preventing foreseeable injury to their patients and third parties. Licensed providers found to have endangered their patients could face disciplinary action and risk loss of licensure as well. Negligence in providing for patient safety may potentially result in large damage awards and threaten a hospital's participation in the Medicare program.22 Infant abductions may be attempted at any time and from anywhere within a hospital. Despite sophisticated security systems and trained personnel, some abductors will be successful. The installation of an infant security system aids in the prevention of infant abductions. However, regardless of the physical environment, anyone desperate enough to abduct an infant may find a method to circumvent the physical security system. Therefore, the key to infant security is staff and parent awareness. Employees should be educated to observe everyone who enters or leaves their facility. Strange and unusual behavior such as hesitation, nervousness, and missing identification bands on anyone holding a newborn must be further observed, especially if an infant is seen in an unusual part of the hospital. Staff members should be empowered to ask the individual holding the baby if he or she is lost or needs assistance. Asking questions such as "How is your baby? When was the baby born? Do you have an appointment today? May I help you?" in a non-threatening way may aid in the assessment of the situation.
It is extremely important to remember that a baby unattended in a mother’s room or nursery—even for a moment—is particularly vulnerable. Every person—parent, family member, friend, and permanent or temporary hospital employee—must be aware of and participate in infant security. Only then will nurses maximize risk management, and only then will infants be protected from becoming victims of infant abduction. For more details on how our infant security system was developed or how our mock infant abduction was managed, please contact Elizabeth A. Mittelstaedt, Lieutenant Colonel, U.S. Army Nurse Corps, Chief, Maternal Child Health Nursing, Madigan Army MEDCEN. Ph: (253) 968-1244; email: elizabeth.mittelstaedt@nw.amedd.army.mil.
References
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Infant
Abduction: A Sentinel Event