56 ‘Abducted Baby’ Simulation: Testing the System to Optimize Patient Safety on a Neonatal Intensive Care Unit

Abstract

Infant abductions are rare distressing events. The Care Quality Commission recently highlighted inadequate protective measures in other trusts as a cause of major concern The aim of the study was to test our existing patient safety system in a real-life situation looking at human factors and equipment functionality.An activated baby tag was placed on a mannequin which was then put into a pram. A member of staff in disguise (the ‘abductor’) pushed the pram out of the neonatal unit by ‘tailgating’ another member of staff so that the doors would not automatically lock, replicating a potential real-life scenario that exploited a known risk. The aim was to see whether the mannequin could leave the hospital. The ‘abductor’ was eventually stopped from leaving. A detailed timeline of events was recorded and analysed. Safety was ensured and participants were individually debriefed as emotions were high.Our simulation highlighted points of excellence including a quick and calm response, the use of the panic button and appropriate persistent challenge of the ‘abductor’ without aggression. Important human factors were highlighted. There is no security staff in the hospital. The ward clerks called the porters directly, rather than dialling 2222 and saying ‘lockdown’, which triggers a lock of all doors out of the hospital. There were several system failures. The baby tag system did not alert the front of house. The panic button was broken, and a set of doors out of the hospital did not lock.Simulation is an effective tool to identify system failures and patient safety risks. This scenario highlighted deficiencies in our system and a lack of established procedures and training. A detailed action plan has been put in place. The panic alarm, door locking mechanism and system linking the baby alarm system to the front of house are being addressed. The option of an automatic lockdown on activation of the baby tag alarm system is being explored. Finally, a standard operating procedure is being written and learning disseminated in the department. We are planning to run this simulation in other areas of the hospital to optimize patient safety.