1. Leadership for Sentinel Events: Infant Abduction at Magee-Womens Hospital of UPMC
Leslie C. Davis
President
Maribeth McLaughlin, RN, BSN, MPM
Chief Nursing Officer & Vice President, Patient Care Services
Magee-Womens Hospital of UPMC
July 17, 2013
3:00 pm ET

2. Sentinel Event: Infant Abduction
Objectives:
Describe the preparedness training and precautions for infant security
Describe the response and support needed for an infant abduction
Describe the steps taken to heal the workforce post an infant abduction
Describe the balance of a safe environment while maintaining your mission and values

3. Sentinel Event: Infant Abduction
Infant Security Task Force - Purpose
Through partnerships, the Infant Security Task Force is dedicated to providing a safe and secure environment that protects our infants, builds trust and enhances the quality of the infant protection program. The task force works both formally and informally to identify issues and concerns and to collectively problem solve.

4. Objectives of the Infant Security Task Force
Reduce the probability of incidents resulting in harm to or abduction of an infant from the hospital.
Identify and analyze vulnerabilities and implement reasonably appropriate safeguards to reduce the number of reportable incidents.
Review practices, processes and procedures to identify areas of improvement.

5. Why a Task Force? “Work at working together”
Small group of people (usually managers) and resources brought together to accomplish specific objectives, with the expectation that the group will persist to look at trends and future endeavors
Understand the unique role each business has in the overall effort. Bring together the subject matter experts to dissect issues and look at trends
Make recommendations to the Security Subcommittee

6. Structure & Membership
Security- Responsible for data collection and analysis. Central repository for all infant protection issues. Works to immediately identify root cause of security breech, disruption or downtime.
Clinical- Responsible for processes tied to infant protection
Identification
Admit/Discharge
Patient Instructions

7. Structure & Membership
Facilities- Responsible for physical assets integrated into the infant program
Doors
Locks
Warning devices/Alarms
Elevators
Information Systems- Responsible for software/hardware, continuity of operations
and servers

8. Components of the Plan:
Infant Security Plan
Components of the Plan:
Identification
Patient Visitation
Infant/Mother Control
Infant Safety Acknowledgement Statement
Access Control and Security Devices
Education
Infant Security System Alarm Response Procedure
Abduction Response Plan
System Outage Procedures
Always know your Census
Security Desk prints a current census at the start of each shift
Direct staff to report any failures/issues
Security makes immediate notification of the outage to:
Security Department Management
IS Department
Administrative Clinician
Facilities Management
Inpatient Nursing Units
Vendor
Security Officers immediately respond to stand post at post partum exits
a copy of the current census
Check all infants leaving the floor against the census
Check infants for security tags and “I’m going home”
Nursing staff immediately account for all infants and verify tag numbers to infants
all infants should be banded and unbanded following normal procedures.
Manual Enrollment Log

9. Response Plan Ensure all staff know their roles/assignments
Create a response matrix
Law Enforcement notification process
Activate the command center and interface with law enforcement command
Engage media relations immediately
Keep in mind multiple events may be occurring (i.e. Bronze Alert)

10. Quality – Routine Checks
Weekly test of a calibrated tag and random sampling – minimum of 5 tags or 10% of inventory
Two trained staff members are needed with the ability to communicate with each other
Standardize the test to reduce errors
Test tags against one door/exit, rotate exits
Test all components of the system monthly
Note: Some of our smaller sites do 100% check

11. Infant Abduction Drills
Infant abduction drills are completed quarterly
Infant security task force meets prior to drill
Discuss past scenarios
Areas of weakness
Test “new” features/upgrades
Test new departments response
Work off past incidents
Review past drill scenarios
Doors stayed open/mom and infant off the unit
Test staff involvement/response and capability of system
Test downtime procedures

12. Education and Preparedness
February 2012 conducted a table top drill:
FBI
Local police
Internal media
Multidisciplinary team of hospital staff and providers
Scenario was an infant abduction with shooting of a nurse by an estranged FOB.
Conflicting response teams:
Condition C rapid response team
Bronze alert (active shooter response)
Infant Abduction Response

13. Education and Preparedness
Purpose of the Drill
Built relationships with local law enforcement and FBI
Understanding of the role of law enforcement and the role of the hospital staff
Gained an understanding of communication issues
Understanding of how to manage multiple events and response plans
Lessons learned…..this could really happen!

14. Education and Preparedness
May 2012 held an Infant Security Summit for UPMC hospitals
FBI presented on infant abductions
Identified the profile of an abductor
Reviewed all Infant Security plans and tried to identify best practices
Installation of more cameras across the facility

15. Sentinel Event: Infant Abduction
Abductor Profile:
Is usually female of “childbearing” age (range now 12 to 53) and often overweight. Abductor 19 years of age and heavy set.
Is most likely compulsive; most often relies on manipulation, lying, and deception. The police characterized abductor as a ‘pathological liar’ and scam artist with an ability to con just about anybody.
Frequently indicates she has lost a baby or is incapable of having one. This is true for abductor.
Is often married or cohabitating; companion’s desire for a child or the abductor’s desire to provide her companion with “his” child may be the motivation for the abduction. Abductor was in a relationship and told the alleged FOB she was pregnant and had a desire to have “his” child.

16. Sentinel Event: Infant Abduction
Abductor Profile (cont):
Usually lives in the community where the abduction takes place. Abductor has close ties to the city and it is believed she intended to stay in the city/area.
Frequently initially visits nursery and maternity units at more than one healthcare facility prior to the abduction; asks detailed questions about procedures and the maternity floor layout; frequently uses a fire-exit stairwell for her escape; and may also try to abduct from the home setting. Abductor visited several area hospitals and visited Magee at least the day before, it is unknown if she had conducted probing activities prior to that.
Usually plans the abduction, but does not necessarily target a specific infant; frequently seizes any opportunity present. Abductor began her planning in early August. 

17. Sentinel Event: Infant Abduction
Abductor Profile (cont):
Frequently impersonates a nurse or other allied healthcare personnel. Abductor impersonated a staff member at least the day before and day of. 
Often becomes familiar with healthcare staff members, staff members work routines, and victim parents. Abductor looked at the white board and obtained the names of nurses, she also learned the names of patients by looking at doorways and eavesdropping on conversations.
Demonstrates a capability to provide “good” care to the baby once the abduction occurs.  The infant had been fed, clothed and was in good condition when found.

18. Sentinel Event: Infant Abduction
8/23/12 Mother and infant are ready for discharge
Mother tells nurses that her sister is coming from work at another hospital
Mother had several family members visiting in scrubs from other hospitals
Abductor on unit on both 8/22/12 and 8/23/23 in visiting with patient
Patient assumes abductor is a hospital employee, staff assume it is a visitor of the patient

19. Sentinel Event: Infant Abduction
Abductor is seen leaving the hospital at 8:30 a.m.
9:00 a.m. She purchased black scrubs with a UPMC logo at the uniform store 2 blocks away
9:31 a.m. She is seen on camera entering the hospital
She is seen on the PP unit and is questioned by staff. States she is visiting her sister (gave a patient name) who is pumping her breast.
12:15 p.m. Abductor approaches RN and states my sister is ready for her Motrin before she goes home (prior conversation between nurse and patient regarding taking Motrin prior to discharge).

20. Sentinel Event: Infant Abduction
Nurse obtains the medication and performs HUGS discharge in the computer.
12:30 p.m. The nurse, mother, infant and abductor all in room when tag is cut off and final discharge occurs. RN leaves the room.
12:55 p.m. Mother goes into bathroom. Abductor has been in room watching TV and states she needs to take the baby for one final test.
12:58 p.m. Abductor is seen leaving the hospital with a large pink purse on video.

21. Sentinel Event: Infant Abduction
1:15 p.m. The FOB approaches nurse’s station asking when the infant would be returned so they can leave.
RN immediately goes to room to see why baby isn’t there.
1:20 p.m. Search of the unit and Condition I initiated, security called and search of hospital is started, 911 activated.
Description of the abductor is given.
1:41 p.m. Police on site. Media out front of hospital, overhead description of abductor
and infant is overhead announced.

22. Sentinel Event: Infant Abduction
Pittsburgh police and FBI respond and take jurisdiction of the hospital and incident command center in security.
Operations command center is opened and staffed.
MWH RN while searching walks to uniform store and gets the receipt of person who bought scrubs.
Hospital Operator gets a call from Florida and a name is given of a suspected abductor posting on Facebook.
Nurses identify abductor on camera footage in command center. Footage tracks her through the hospital on 8/22 & 8/23.
Detectives conduct interviews with patients, staff and visitors.

23. Sentinel Event: Infant Abduction
The purchased uniform is found in a dumpster across the street from the hospital.
2:00 p.m. TJC and DOH are notified of sentinel event.
Media communications are being coordinated between the police and hospital media relations staff.
Mother and family moved to a remote unit for privacy as family members coming into hospital.
Mother’s room is sealed off as finger printing and pictures are obtained (crime scene).
Police and staff are able to confirm postings and pictures on Facebook.

24. Sentinel Event: Infant Abduction
MR of the now known abductor are reviewed. Profile is matching that of an abductor.
Operations command center and police command center coordinating activities to maintain operations.
Resolve Crisis center staff on site for employees.
Police are able to triangulate her location through Facebook postings from cell phones.
6:00 p.m. Abductor is located in a building in the city of Pittsburgh. She has shown the baby to the alleged FOB.
6:20 p.m. Baby is returned to MWH ED and examined. Police ask for footprints and DNA testing.
Confirmation by RN who assessed baby.

25. Sentinel Event: Infant Abduction
6:40 p.m. Baby is reunited with family. Decision made to keep them overnight to observe baby over night.
Patient requests to go back to the unit she had been on.
8:00 p.m. Debriefing with police, FBI, hospital staff and internal media occurs.
8/24/12 Entire situation is debriefed again. Temporary measure are put in place to increase security, visitor control, revision to our policy on discharge, mandatory in-services are set up for staff.

26. Healing the Workforce During the Event:
Frequent communication from the President to employees and physicians via
On site crisis counselors from WPIC brought in immediately to assist staff
Deployed management to round in all areas of the hospital and provide support
Senior leadership provided support to staff being interviewed by detectives

27. Healing the Workforce During the Event (cont):
Unit staff provided relief and additional staffing resources
Notification to Community Board Members
Communication to Corporate and Media Relations
Brief communication distributed to patients to balance media on television

28. Healing the Workforce After the event:
Transparency and just culture related to RCA of the incident
Staff debrief with crisis counselors after return of infant and arrangements are made to have counselors on site for next two weeks for any staff
Specific meetings with Nursing staff and Security staff
President conducted open forum town hall meetings in the auditorium explaining the events and allowing for questions. Support from Pastoral Care
Created a site on our infonet to allow for security suggestions by staff
Uninvolved staff (MedSurg) sent notes and gifts of support to the OB staff

29. Sentinel Event: Infant Abduction
Actions Taken to date:
Visit from the Center for Missing and Exploited Children with assessment of the facility. Three recommendations taken:
Remove Mother’s first name from all door and bed cards
Ensure all locker rooms are locked
Place signage highlighting cameras throughout hospital
Tightened the discharge process and auditing it
More signage in room about the stork and safety measures
Visit by DOH and Call with TJC both accepted our plans of correction
Evaluation of more door accesses locked
Corporate changed the contract with uniform
vendors

30. Enhancing the Security Plan
Balancing the Mission and Values while maintaining a secure environment
Tightening up the visitation policy for obstetrics
Enhancing the visitor management system in a high volume delivery service (11,000 deliveries)
Maintaining a family centered approach
Mandatory training for all staff and providers on site
Education on the profile of the abductor

31. Enhancing the Security Plan
Continuing to care for patients who meet the profile of the abductor
Balancing HIPPA with sharing information on concerning patients with staff
Example:
Patient who is unable to get pregnant has presented multiple times claiming she is pregnant to a clinic/ ED.
Brain injury patient who is 65 and claims to be pregnant calling and presenting to hospital

32. Enhancing the Security Plan
Formation of a PFCC Care Experience team for Secure Environment
Shadowed the experience
Interviewed patients about security measures
Membership included OB provider offices, Outpatient clinic, Pediatrics, security, nursing, transport, consumer education, etc.
Development of branded educational materials to include room signs, brochures, website, video, signage

33. Sentinel Event: Infant Abduction
Take Aways:
Over communicate with the staff what transpired
Staff are experiencing Post Traumatic Stress
Drill with local Law Enforcement and media
Even more education with parents
Audit the process to ensure that all are following it
Need for redundancy and layers of security
World has changed: staff being trusting of patients and visitors

34. Questions?
Comments?

35. Thank You