BURAIDAH C ENTRAL H OSPITAL

Department : NURSING SERVICE Policy Index : PP-BCH-NR/GNR-018-IPP-E Title: ABDUCTION OF INFANT / CHILD ( CODE PINK ) Effective Date : Applies to: 01-01-1432 H Hospital - Wide New

B. C. H.

IPP

Replace Number : XXXXX

Number of Pages : 4 Review Due : 01-12-1433 H

1. PURPOSE : 1.1 To prevent the abduction of infant in the Hospital or Health Care Units.
1.2 To provide safe and secured environment for babies who are unable to protect themselves. 1.3 To define the health care facility response to an infant abduction.

2. DEFINITIONS :
2.1 Infant Abduction - is the taking of a child less than 1 year old by non -family members. 2.2 Code Pink - refers to the procedures to prevent the unauthorized removal of an infant or child from the Hospital / Health Care Facility.

3. POLICY: 3.1 Nurses should observed strict adherence to newborn identification system. 3.2 Matched ID band must be presented to Nursery Staff, when mother or significant other comes to Nursery for breastfeeding. If any doubt, staff should accompany the baby to the mothers room to confirm. 3.3 Mothers should be instructed to release their baby only to staff wearing appropriate iden tification. 3.4 Babies should only be transferred to other department per bassinet /crib, anyone carrying a baby in the hallway should be inspected. 3.5 During visiting time, nursery door should be monitored and locked, an authorized staff will always be present.

Prepared by: Ghada Falah Al-Harby Staff Nurse

4. PROCEDURES :

Approved by: Ahmad Abdulla Al- Omar Hospital Director

Page Number: 1/4

Approval Stamp

Form Index: BCH-QM-009-E

4.1 All staff will be required to wear proper identification at all times. 4.2 Hospital scrub and laboratory coats will be kept in an access - controlled area and are not to be loaned to an unathorized personnel.

4.3 Staff will ensure that infants are always in the direct -line of-sight of parents or hospital staff. 4.4 Parents will be informed of security measures as early as possible, after the birth of the infant. 4.5 Parents will be instructed to tell family members to use the visitors elevators, not the staff elevators or stairs. 4.6 Only an unauthorized staff are allowed to transport an infant while in the hospital. 4.7 Parents or staff members are not allowed to carry the infant outside mothers room or with in the hospital at anytime. 4.8 Staff Nurses will immediately report any unidentified individuals, suspicious activity or be haviour or unfamiliar persons to the Charge Nurse.The Charge Nurse will in turn contact the Security Department. 4.9 Staff Nurse will require everyone entering the Nursery, PICU, Labor Room.OB Ward to identify themselves and reason for their visit, visitors without guest passes will be directed to Hospital Information Desk. 4.10 At delivery , the mother and infant will be handed with identically numbered. 4.11 Foot print of the newborn should be taken immediately after delivery and place the new born identification sheet on the patients charts, the chart is to be kept in a secure location at all times. 4.12 In the event of multiple gestation, the parents will be handed with a numbered identifica tion bracelet for each infant. 4.13 The identification bracelet will be secured to the infant at all times 4.14 If the parents numbered identification band is lost, or illegible, the parent and infant will be re-handed after confirming the parents identity. 4.15 The parents numbered identification band must be shown to the staff when requested. 4.16 Photograph of the infant will be obtained by the first photo technician as soon as possible after admission. 4.17 In suspected or actual infant abduction the Charge Nurse or his / her designee will announce Code Pink in Progress over the unit, dialling Ext.2432 (Security Department) and the Security Department will call the Assistant Manager during the official working time. On Call Manager to be informed on Ext. 2424, one doctor from ER. has to be in formed , Nursing Director and Patients Relation Manager. 4.18 All Nursing Staff members will check to see that each of their assigned babies is present and accounted for. 4.19 During intervening period, all other staff members are expected to look for suspicious persons on the Unit. 4.20 The Charge Nurse must call the Security Department and report that each baby is or not accounted for.: 4.20.1 The Staff member suspecting an infant abduction will conduct a brief seach of the immediate vicinity e.g. patients room and nearby hallway. 4.21 If the Policy Number:
Approval Staff member continues to suspect an infant abduction, Number: Title: Page the Charge Nurse is notified ABDUCTION OF INFANT / CHILD ( CODE PINK ) 2/4 Stamp

PP-BCH-NR/GNR- 018- IPP-E

Form Index: BCH-QM-009-E

immediately.: 4.21.1 The Charge Nurse / her or his Designee announces Code Pink in progress.

4.22 The Nursing Staff members will immediately check to see that each baby in their care is present and accounted for. 4.23 If there is reason to suspect that a baby may be in another vicinity on the unit or floor, e.g. Treatment Room, or Mothers Room those rooms are quickly checked before calling the Security Department. If theres little or no reason to suspect that a baby may be in another vicinity on the Unit, The Security Department are to be called imme diately. 4.24 The Security Department will block all of the Exits. 4.25 Once Code Pink is announced. No location is given since Pink affects all Hospital Units. 4.26 All Exit Doors are immediately observed and blocked by all available Security Staff. 4.27 All persons are detained from leaving the unit until cleared by the Charge Nurse and / or the search of the unit has been completed. Note : Its important to remember to search in unlikely places such as : closet, beneath beds behind curtains, in offices, in call rooms, in locker rooms, in dumpster etc 4.28 Security Staff should stop the flow of traffic going out of the Hospital Unit until authorities arrive. They will search around the Hospital and assigned a female staff to search in the female area. 4.29 Once the abduction has been confirmed, the attending physician should notify the pa rents; high confidentiality should be kept by the Security staff and the Hospital team members medical and non - medical . 4.30 All staff on duty when the abduction occurred will remain in the unit until authorities com pleted proper investigations. 4.31 Document the incident from the discovery of the abduction until the infant is located. Incident Report / OVR should be accomplished. Care of The Family Experiencing An Infant Abduction : 1. Move the parents of the abducted infant to private room. 2. Have the nurse assigned to the infant, remain with the parents at all times. Other Administrative Duties of The Charge Nurse in Code Pink : 1. Locate and secure the infants medical records. 2. Locate and secure the infant blood sent for metabolic screening or, if available, other blood samples.

5. FORMS AND EQUIPMENTS :

5.1 OVR Form / Incident Form.

Policy Number:

6. REFERENCES :

PP-BCH-NR/GNR- 018- IPP-E

Title: ABDUCTION OF INFANT / CHILD ( CODE PINK )

Page Number: 3/4

Approval Stamp

Form Index: BCH-QM-009-E

6.1 Maternity and Childrens Hospital Policy and Procedure Manual.

7. APPENDIX :
7.1 N/A.

8. APPROVAL:

Name Prepared by: Ghadah Falah Al-Harby 1. Abdulla Obeid Al-Harby 2. Ibrahim Al - Anezi Reviewed by: 3. Ehab El Husseiny 4.Manae Al-Belaihy Approved by: Ahmad Abdulla Al-Omar

Position Staff Nurse Nursing Director Head of Safety Security Department QM Director Medical Director Hospital Director

Signature

Date
22-11-1431 H 24-11-1431 H 29-11-1431 H 29-11-1431 H 29-11-1431 H 01-12-1433 H

Policy Number: PP-BCH-NR/GNR- 018- IPP-E

Title: ABDUCTION OF INFANT / CHILD ( CODE PINK )

Page Number: 4/4

Approval Stamp

Form Index: BCH-QM-009-E

Policy Number: PP-BCH-NR/GNR- 018- IPP-E

Title: ABDUCTION OF INFANT / CHILD ( CODE PINK )

Page Number: 5/4

Approval Stamp

Form Index: BCH-QM-009-E