Cases & Commentaries
Approach to Improving SafetySafety TargetSetting of CareClinical AreaError Types
- Define elopement and differentiate it
from wandering and leaving against medical advice.
- Identify leading contributors to
- Describe strategies for preventing
elopement and steps for responding after a patient elopement has
- Identify legal risks associated with
Case & Commentary: Part 1
A 61-year-old male with a history of chronic
pancreatitis and cardiomyopathy attributed to alcohol was admitted
for chest pain, acute on chronic renal failure, and altered mental
status. After being treated for his worsening cardiomyopathy and
renal failure, his mental status began to clear. On the morning of
anticipated discharge, he was not in his room at the time of the
physician's visit. Such behavior was typical for this patient, who
was known for being one of the hospital's "frequent flyers."
However, when he did not return 3 hours later, security was called
to locate him.
Finding that a patient has "gone missing" is a
scary situation for providers and patients' families. According to
the VA National Center for Patient Safety (NCPS), elopement
is defined as: "A patient that is aware that he/she is not
permitted to leave, but does so with intent."(1) In many cases of elopement, the patient may have a
decreased mental capacity related to dementia or temporary
delirium, or intermittent mental status changes related to
medication, disease, or traumatic injury.(2) Despite the level of capacity or intent, both of which
may be difficult to determine, eloping patients are often at risk
for serious harm, and there are many cases where patient elopement
has resulted in death.(3) On
the other hand, wandering refers to a patient who "strays
beyond the view or control of staff without the intent of leaving
Wandering can also lead to significant safety risks when the
patient has decreased capacity.(2)
(For more information on elopement terminology, see Table.)
Leaving against medical advice (AMA) is different
from elopement or wandering and is determined by the patient's
decision to leave the facility having been informed of and
appreciating the risks of leaving without completing
Fully competent patients are legally able to discharge themselves
without completing treatment. In such cases, the physician should
inform the patient of the risks associated with leaving. In most
organizations, this conversation is recorded in the medical record
and the patient is asked to sign a form indicating that they are
aware of the risks and that they are leaving against medical
advice. Patients who are able to make determinations about their
own care should be given guidelines upon admission that outline
their rights and responsibilities while hospitalized, including the
need to communicate with staff prior to leaving a treatment
The Joint Commission's sentinel events policy
defines "any elopement, that is unauthorized departure, of a
patient from an around-the-clock care setting, resulting in a
temporally related death (suicide, accidental death, or homicide)
or major permanent loss of function" as a reportable sentinel
This reporting requirement reflects the level of harm to the
patient regardless of the patient's intent to leave or mental
capacity. The National Quality Forum has defined 27 serious adverse
events and includes death or serious harm associated with elopement
(disappearance) for more than 4 hours among its list of patient
According to Joint Commission sentinel event statistics, the
primary contributors to elopement are breakdowns in patient
assessment and team communication.(7)
Protection of patients from elopement risks requires attention to
preventive measures through assessment and elopement precautions as
well as appropriate intervention after elopement occurs.
Adequately assessing patients for elopement risk
factors and use of elopement precautions can prevent elopement and
Such an assessment and possible precautions have been outlined in
an elopement tool kit created by the VA Center for Patient
"yes" to any of the following assessment questions indicates that
the patient is at risk for elopement:
- Does this patient have a court-appointed
- Is this patient considered to be a
danger to self or others?
- Has this patient been legally
- Does this patient lack the cognitive
ability to make relevant decisions?
- Does this patient have a history of
escape or elopement?
- Does this patient have physical or
mental impairments that increase their risk of harm to self or
In this case, the patient had a known history of
altered mental status at the time he was deemed to be missing from
his room, and his disappearance was not an uncommon event. Using
the VA criteria, he clearly was at risk for elopement. For patients
who have intermittent mental status changes, it is foreseeable that
they could be at risk for serious harm if their capacity changes at
a time when they are not adequately supervised. For this reason,
the physician and staff in this case should have initiated
elopement precautions despite his pending discharge and
Patient care involves many gray areas in which
professional judgment is required. Keeping the patient safe is the
primary goal and should guide all decision making. For patients who
are competent and who have left the area without informing staff,
response to their absence is based on what is reasonable for the
particular situation. For some organizations, an absence of 45
minutes triggers the elopement protocol and patient
Other organizations deem elopement response necessary when "it
becomes reasonably certain the patient is missing without
prevent unnecessary searches, units should have procedures in place
for patients to sign out or otherwise communicate with the nursing
staff before leaving the area.
Frequently referred to as "Code Green," the
response to elopement requires both actions by staff in the area
from which the patient is missing as well as an organization-wide
response. A typical protocol includes the following steps:
- Notification of the operator by unit
staff indicating a Code Green/Elopement.
- Notification of security with a
description of the missing patient and pertinent clinical
- Notification of the patient's
- Immediate search of the unit and
surrounding area by unit staff.
- Immediate search of hospital and grounds
by security personnel.
- Notification of the patient's family by
- Notification of police by security as
- Notification of appropriate
Procedures differ among organizations. However,
the key is to do what is reasonably necessary to return the patient
to a safe environment. Patients who have been missing for a
significant period of time, most typically 4 hours, are typically
readmitted rather than just returned to their unit. Other
organizations use midnight as the indicator.(10,12) Providers should consult with organization
policies for specific guidelines.
Case & Commentary: Part 2
Ultimately, the patient was found outside of
the emergency department (ED), with ED Discharge Instructions in
his hand. The patient apparently told the ED staff that he had
recently been discharged and was waiting for a ride. He was brought
into the ED. Because he was a "frequent flyer" there and complained
of pain, he received his "usual" 1 mg of intravenous Dilaudid and 2
liters of intravenous hydration and was promptly released with oral
pain medications, despite being noted as mildly confused by the ED
staff. In the course of his ED visit, no one questioned the
presence of a hospital ID bracelet and hospital gown; additionally,
the hospital computer system failed to recognize that the same
patient had been admitted simultaneously to both the inpatient
floor and the ED.
An immediate organizational response should be
initiated when any patient with decreased mental capacity has left
the unit or treatment area without authorization. Health care
organizations should have policies and procedures in place
indicating the steps that personnel are to follow in any elopement
situation, and adequate training should be provided for all staff.
These protocols should include assessment and prevention procedures
to reduce the risk of harm for patients with diminished capacity.
Such preventive measures may include placing the patient on an
observation protocol (special precautions for patients requiring
frequent or constant monitoring). Such a protocol may include
locating the patient close to the desk, placing an electronic
monitoring device on the patient when available, partnering the
patient with a roommate, or requesting a family member or nursing
assistant to sit with the patient. Additional precautions common in
mental health and rehabilitation facilities include automatic door
locks, alarms, and diversion activities.(13)
In the case above, we cannot determine if there
was not a policy for staff to follow or if they merely failed to
follow the existing policy. If inpatient staff had initiated a Code
Green type of response, it would be likely that the ED staff would
have been aware of the missing patient and may have noticed that he
was in their area before discharging him (provided that the
procedure notified all areas of the facility). Adequate
communication of such an event across the entire organization is
essential so that a concerted effort can be made to locate the
patient and safely return him to an appropriate level of care.
Given the recurring shortage of staff and the
increasing complexity of patient care, use of technological
solutions to prevent elopement is becoming more common.(14)
Use of radiofrequency (RF) devices can make the difference,
particularly when they are paired with routine risk assessment and
solid team communication. Wrist bracelets (15) that are linked to signal detection devices within
the unit can trigger an alarm when a patient wanders too far from
their room. This helps staff who are busy with other patients and
who may not notice when the patient leaves. In some facilities, the
alarm can be linked to systems that automatically lock doors. In
one ED, the use of the RF devices and a new triage protocol reduced
the need for one-to-one monitoring of at-risk patients by
Care of patients in health care facilities is
predicated on the patient's consent to treatment. Patient consent
is obtained on admission to a facility and often throughout the
course of a hospitalization for particular procedures. When a
patient is mentally able to consent to treatment and is able to
fully partner with health care professionals, the decisions of the
patient regarding receipt of care must be honored. Competent
patients who choose to leave without completing treatment cannot be
held against their wishes. Doing so damages trust and impacts the
reputation of the facility. In addition, providers would be at risk
for claims of assault, battery, or false imprisonment.(17)
In all situations, including this case, there is
a legal duty to exercise reasonable care and attention for the
patient's safety, as their mental and physical conditions may
render them unable to look after their own safety. Health care
professionals have a duty to adequately supervise and observe
patients and to maintain safe conditions on the premises.(18)
Additional liability can ensue when there is negligent
administration or failure to administer medications, when there is
failure to notify the physician of changes in the patient's
condition, and in situations where there was a failure to properly
search for the patient following elopement.(19) Patients with diminished capacity, such as in this
case, pose a threat to themselves and perhaps to others. Failing to
initiate an immediate system-wide search put the patient at further
risk and created a liability risk for the providers and the
Linking adequate assessment, precautions, good
team communication, updated technology, and immediate system
response with an overarching goal of safe patient care can improve
outcomes for patients at risk for elopement, reduce costs, and
limit liability for care providers and the organization.
- Elopement is a serious event that
requires a system-wide, organized response.
- Breakdowns in team communication and
patient assessment are the top contributors to elopement
- Patients should be assessed for
elopement risk on admission and throughout their
- Patients at risk for elopement should be
put on special preventive precautions.
- Response to elopement by patients with
diminished capacity should be immediate and include unit staff,
security, and, when appropriate, local authorities.
Debra Gerardi, RN, MPH, JD
Chair, Program on Healthcare Collaboration and Conflict
Werner Institute for Negotiation and Dispute Resolution
Creighton University School of Law
Faculty Disclosure: Ms. Gerardi has
declared that neither she, nor any immediate member of her family,
has a financial arrangement or other relationship with the
manufacturers of any commercial products discussed in this
continuing medical education activity. In addition, the commentary
does not include information regarding investigational or off-label
use of pharmaceutical products or medical devices.
1. DeRosier JM, Taylor L. Analyzing missing
patient events at the VA. TIPS (Topics in Patient Safety).
November/December 2005;5:1-2. Available at: http://www.va.gov/ncps/TIPS/Docs/TIPS_NovDec05.pdf.
Accessed December 6, 2007.
2. Kosieradzki MR, Smith JE. Common
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Accessed December 6, 2007.
10. Stanford Hospital and Clinics. New policy
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12. The University of Connecticut Health Center
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|VA NCPS definitions
patient—A patient who "is aware that he/she is not
permitted to leave, but does so with intent."
patient—A patient who "strays beyond the view or control
of staff without the intent of leaving (cognitive
patient—"A patient missing from a care area without staff
knowledge or permission."
Elopement—legally defined as a patient who is
incapable of adequately protecting himself, and who departs the
health care facility unsupervised and undetected.
Wandering—defined as occurring when patients aimlessly
move about within the building or grounds without appreciation of
their personal safety.
*Note: These are general legal
definitions; variations will occur from state to state.