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Infant abduction drills could have your code pink team seeing red

Healthcare Security and Emergency Management, December 5, 2003

Infant abduction drills could have your code pink team seeing red
Examine the details of your hospital’s infant abduction procedures


Chances are you’ve developed a plan to deal with an infant abduction. But have you scrutinized the smaller details of your plan?

For example, in most hospitals, almost anyone can call the code for an infant abduction, but who is authorized to cancel it? Also, what would happen if an infant abduction prevention system failed?

Here are some examples of how a few hospitals dealt with these and other kinks in their infant abduction plans.

Exposing the weaknesses
A savvy and motivated abductor can compromise your prevention plans and confuse your staff. Look at the curveball thrown to North Colorado Medical Center in Greeley, CO, during a recent infant abduction drill.

Hospital staff placed a life-sized baby doll in the nursery, complete with an electronic security band around the doll’s ankle. A female security officer from a nearby hospital posed as the baby snatcher.

“The abductor dressed in nurse’s scrubs and had an identification card from another hospital,” says Paul Reimer, MS, HEM, CHMM, safety officer at the hospital.

Once she made it to the infant ward, she rigged the door so that the magnetic lock was ineffective, Reimer says.

“After cutting the electronic band off of the doll’s ankle, the system activated like it was supposed to, but didn’t lock the door because it was rigged. The abductor easily left the ward with the baby doll.”
As if rigging the lock wasn’t bad enough, the abductor’s next move showed staff how easy it would be to abduct an infant with knowledge of hospital security.

“After leaving the infant ward and hearing the abduction code on the overhead page, she walked the halls for a few minutes with the abducted baby doll, and then stopped at a house phone in the hallway,” Reimer says. “She then calmly called the switchboard, told the operator she was [an officer] from the security department, said the baby had been found, and told the operator to cancel the code pink.”

The operator immediately cancelled the abduction code with a hospital wide page without confirming the officer’s identity.

In this case, the hospital put in place technological safeguards and had a coordinated staff response, but the abductor was able to bypass those and confuse staff into thinking everything was okay.

“The person playing the abductor . . . had a security background and had a good idea how to get by security measures,” Reimer says.

Indeed, there is only a slim chance a real abductor would know security procedures or actually take the time to study a hospital’s security system that closely, but Reimer says the episode illustrates the attitude staff must take when dealing with infant abductors and planning prevention.

“You never know what to expect if an abductor is really motivated to take a baby. That is why you must constantly conduct different drills to find out where the kinks are in your response plan,” says Reimer.

In this case, the abductor bypassed the technological protections and exposed a loophole in staff procedure for canceling the abduction code.

“The operator who took the call had no idea who was or wasn’t on the security staff, so she didn’t realize the call was a fake,” says Reimer.

The hospital changed its policy regarding the cancellation of infant abduction emergencies after reviewing the drill. Now, a uniformed officer goes down to the switchboard and tells the operator to cancel the code.

Variations on a theme
A similar situation occurred at a Midwest hospital that asked not to be identified. There, a young relative of a patient was reported missing while visiting the hospital, and officials immediately called a missing-child code.

When the child reappeared, the family called the switchboard and an operator cancelled the abduction code without first checking with security.

After that incident, the hospital changed its policy so that only obstetrics staff or the unit director can call or cancel an abduction code. “These positions are staffed 24 hours,” the hospital spokesperson said. “When they call the switchboard to cancel a code, they must provide their full names and titles.”

Crying wolf
Both of the above cases reveal problems in the cancellation procedures for infant abduction and missing child responses. Another challenge in these procedures is the “false” infant abduction alarm.
The electronic band system used by North Colorado Medical Center is similar to systems used in many hospitals.

With this system, a nurse providing care for an infant can accidentally set off abduction alarms by tampering with the band or bringing a baby too close to a sensor.

“False alarms have been a serious issue here,” says Murray Hayward, chief safety officer at University of Utah Hospitals and Clinics in Salt Lake City.

“[We realize] a system that is subject to an excessive number of false alarms will become ineffective over time . . . if the system cannot accurately discern false alarms from actual events.”
Murray recently reviewed four different abduction prevention systems, but all produced an excessive amount of false alarms. A common sentiment from employees using the systems is, “We get used to it . . . considering the cost of these systems, they need to be more reliable than they are,” says Murray.

Regardless of the status of the infant abduction prevention system, Hayward developed a detailed procedure for the initiation and cancellation processes of a code pink for his health system.

“Our alarms can only be initiated by the nurse manager or charge nurses of the affected units,” he says. “They provide information to the incident commander who drives the overall response.

The incident commander is the only person authorized to cancel an abduction code. These positions are all staffed 24/7 to ensure a consistent response.”

Lessons learned
As in the cases above, there might be problems with your infant abduction plans.

Consider the following points the next time you review your program.

• Develop a procedure to cancel an infant abduction code other than simply calling the switchboard. Authorize a 24-hour staff position to cancel the code, or develop a procedure to identify the person authorizing the cancellation.


• Look at your technological safeguards to keep potential abductors at bay. An abductor can easily rig a system to his or her advantage. For example, develop layers of security to backup a failed door lock.


• Constantly conduct drills that test different parts of your abduction prevention plan. Test your plan on all shifts. Vary your scenarios to test all elements of the plan.


• Check your electronic band systems for false alarms. Continuous false alarms wear on infant ward staff, and could cause complacency that can contribute to a real abduction.


• Work with vendors to develop procedures to decrease the number of false alarms and pass that information on to staff. Analyze all false alarms for recurring problems and change staff procedures to address those concerns.


• Work with other hospitals to develop infant abduction drills using each others security staff. Security team members who act as abductors during drills will know the safeguards in place, and can easily point out security breaches.