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Leadership for Sentinel Events: Infant Abduction at Magee-Womens Hospital of UPMC July 17, 2013 3:00 pm ET Leslie C. Davis President Maribeth McLaughlin,

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Presentation on theme: "Leadership for Sentinel Events: Infant Abduction at Magee-Womens Hospital of UPMC July 17, 2013 3:00 pm ET Leslie C. Davis President Maribeth McLaughlin,"— Presentation transcript:

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

2 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 Sentinel Event: Infant Abduction 2

3 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. Sentinel Event: Infant Abduction 3

4 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. Objectives of the Infant Security Task Force 4

5 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 Why a Task Force? 5

6 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 Structure & Membership 6

7 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 Structure & Membership 7

8 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 Infant Security Plan 8

9 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) Response Plan 9

10 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 Quality – Routine Checks 10

11 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 Infant Abduction Drills 11

12 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 Education and Preparedness 12

13 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! Education and Preparedness 13

14 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 Education and Preparedness 14

15 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; companions desire for a child or the abductors 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. Sentinel Event: Infant Abduction 15

16 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. Sentinel Event: Infant Abduction 16

17 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. Sentinel Event: Infant Abduction 17

18 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 Sentinel Event: Infant Abduction 18

19 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). Sentinel Event: Infant Abduction 19

20 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. Sentinel Event: Infant Abduction 20

21 1:15 p.m. The FOB approaches nurses station asking when the infant would be returned so they can leave. RN immediately goes to room to see why baby isnt 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. Sentinel Event: Infant Abduction 21

22 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. Sentinel Event: Infant Abduction 22

23 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. Mothers 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. Sentinel Event: Infant Abduction 23

24 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. Sentinel Event: Infant Abduction 24

25 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. Sentinel Event: Infant Abduction 25

26 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 Healing the Workforce 26

27 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 Healing the Workforce 27

28 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 Healing the Workforce 28

29 Actions Taken to date: Visit from the Center for Missing and Exploited Children with assessment of the facility. Three recommendations taken: –Remove Mothers 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 Sentinel Event: Infant Abduction 29

30 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 Enhancing the Security Plan 30

31 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 Enhancing the Security Plan 31

32 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 Enhancing the Security Plan 32

33 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 Sentinel Event: Infant Abduction 33

34 Questions? Comments? 34

35 Thank You 35

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