Patient Abduction
Cause Mapping Example:
The abduction of a patient of any age from a medical facility is one of the "never events" as defined by The Joint Commission. Although the concern is patients of any age, the most publicized abductions are those of infants from the maternity ward, or NICU. Since the most information is available about infant abductions, we will perform a proactive root cause analysis of infant abductions. A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page. A proactive root cause analysis investigation covers the possibilities that COULD lead to an issue, rather than analyzing what DID happen during an actual issue. This allows us to come up with solutions without waiting for a patient abduction to happen.
In order for a infant abduction to occur, the infant and abductee must be allowed to leave the hospital. To do this, the abductee must obtain the infant, and the hospital must have inadequate security. We'll look at each of these causes in turn.
The security could be inadequate due to a lack of physical security. This could include the lack of an alarm system on the infants, or exits (including stairs, elevators, and emergency exits) not being access controlled. Additionally, a lack of questioning by staff could lead to inadequate security. This could be because the baby is hidden in a bag, or because the abductee is dressed as a staff member. This could occur if the abductee has stolen an employee uniform and/or badge, possibly because the staff room is left unlocked.
The abductee could obtain the infant by either taking an unsupervised baby from a bassinet, or obtaining the baby from the mother. The mother may give up her baby if she believed it needed to be taken for tests, etc, due to an inadequate knowledge of hospital procedures, and if she believed the abductee was a staff member. This could be because the abductee had on a uniform and/or badge, as discussed above, or if the abductee had ingratiated herself to the mother, possibly by pretending to be a volunteer.
Even more detail can be added to this Cause Map as the analysis continues. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals. Once the Cause Map portion of the root cause analysis is complete, solutions can be found, to prevent abductions of infants, and other hospital patients.
Click on "Download PDF" above to download a PDF showing the Root Cause Analysis Investigation.
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