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
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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
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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.
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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.
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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
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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
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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
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Infant Security Plan
Components of the Plan:
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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
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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)
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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
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Infant Abduction Drills
• Infant abduction drills are completed quarterly
• Infant security task force meets prior to drill
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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
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Education and Preparedness
• February 2012 conducted a table top drill:
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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
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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!
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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
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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.
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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.
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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.
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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
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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).
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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.
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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.
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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.
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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.
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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.
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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.
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Healing the Workforce
During the Event:
• Frequent communication from the President to
employees and physicians via email
• 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
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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
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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
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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
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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
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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
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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
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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
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Questions?
Comments?
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Thank You
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