146 - Iterative Simulation and Healthcare Failure Mode Effects Analysis Improves Child Abduction Response Systems Over 3 Years of Testing in a Children's Hospital

Publication Number: 146.5921

Dani Bruno, The Barbara Bush Children's Hospital at Maine Medical Center, Portland, ME, United States; Brian C. Richardson, The Barbara Bush Children's Hospital at Maine Medical Center, Portland, ME, United States; Max Doane, Maine Health Barbara Bush Children’s Hospital, Portland, ME, United States; Marissa Perry, The Barbara Bush Children's Hospital at Maine Medical Center, Portland, ME, United States; Micheline Chipman, The Barbara Bush Children's Hospital at Maine Medical Center, Portland, ME, United States; Leah Mallory, Barbara Bush Children’s Hospital, Portland, ME, United States; Jamie Fey, Tufts University School of Medicine, Portland, ME, United States

Background: Child abduction from healthcare facilities is rare but presents serious risk to patients, families, and staff.1 The National Quality Forum classifies this as a “never event,” or a preventable error with serious consequences.2 Limited data on optimizing preparedness is available and often focuses on nursery abductions. Healthcare Failure Mode Effects Analysis (HFMEA) with in-situ simulation effectively identifies latent safety threats (LSTs) and can prospectively improves patient safety.3

Objective: Use iterative HFMEA with in-situ simulation to identify LSTs, train staff, and optimize child abduction response systems.

Design/Methods: An interprofessional team of medical, nursing, security, emergency management, and safety personnel conducted annual in-situ child abduction simulations from 2022 to 2024. They used simulation with HFMEA to test response systems, identify LSTs, and develop remediation plans. Each year's simulation built on prior findings and increased in complexity. LSTs were categorized and scored based on probability and severity, generating a total Hazard Score (Table 1). Results were shared, mitigation plans created, and strategies retested with each increasingly complex iteration.

Results: 49 LSTs were discovered, 23 of which were “critical” (≥8) (Table 2). Key improvements included updating the institutional policy, transitioning to plain language codes, scripting communication, and developing a “child abduction response kit.” Each year, a similar number of critical LSTs persisted, but their intricacy evolved. In 2022, charge nurse task saturation led to a checklist for task delegation, (e.g. room searching). In 2023, LSTs revealed gaps in search task delegations when areas were missed, prompting the development of a more thorough response kit. By 2024, testing showed staff inability to access some assigned areas, requiring further protocol refinement. Repeated LSTs, such as challenges to obtain an accurate headcount, indicate a need for ongoing updates.

Conclusion(s): Iterative simulation and HFMEA can effectively identify LSTs and inform mitigation strategies to improve system readiness for child abduction events. Annual simulations with increasing complexity engaged community stakeholders to test protocol improvements.
References
1. Pandya et al., Improving Hospital Preparedness for Pediatric Abductions 1. 38(Suppl. S1): s216-217
2. National Quality Forum, Serious Reportable Events in Healthcare 2011.
3. DeRosier et al., Using Healthcare Failure Mode and Effect Analysis 27(5): 248-267.

HFMEA Hazard Scores Based on Severity and Probability


Latent Safety Threats with Critical Hazard Scores and Mitigation Strategies