Start/Search | Browse by Day | Author Index

In order to ensure the safety and security of babies born in a hospital, a solid infant security plan and process is required. According the National Center for Missing and Exploited Children (2009), California has the highest infant abduction rate in the nation. The Joint Commission (1999) considers an infant abduction as a sentinel event and the Center for Medicaid and Medicare Services (2008) has listed abduction of a patient as a Never 28. In response to the Joint Commission’s requirement to perform an annual proactive risk assessment of a high risk process, this community hospital chose to evaluate its infant security program. Despite the presence of an electronic infant security system, there were breakdowns in the infant security process leading to potential risks for infant abduction. In addition, analysis of historical data revealed operational cost of greater than $5000 per year related to lost infant security tags.

Description of the innovation and resulting change:

Nursing leadership in collaboration with staff nurses and security personnel from Sharp Grossmont Hospital Women’s and Children’s Services conducted a “workout” and a failure mode effect analysis lead by a Six Sigma change agent to examine their infant security program and identified areas of vulnerabilities within the process. A workout is a process improvement method that uses a concentrated decision making session involving the people who do the work to solve the problems. The multidisciplinary team developed an innovative strategy to minimize infant security risks and decrease operational cost. Outcomes

All staff including security personnel were educated on the risk factors for infant abduction, profile of an infant abductor, liability issues, the proper response to infant security alarms, and the new infant security discharge process. This change process was implemented February 1, 2009. As a result of the change process, a cost savings of $2,400 has been achieved related to lost tags. In the past, security had a passive role in infant security, but now has a very active role by participating in the discharge process for every baby that leaves the hospital. Nurses have a heightened sense of awareness for infant security. Staff morale and attitude has improved with the new discharge process. An effective and efficient reconciliation process was established. By using the Six Sigma change process and establishing a multidisciplinary approach to infant security, participants were able to unravel a huge concept, systematically analyze the gaps, and agree to a plan of action thereby, enhancing and strengthening the existing infant abduction prevention measures, hard wiring the importance of infant security minimizing the vulnerabilities, and decreasing operational costs.