Presentation
From Single Events to Systemic Insights: Lessons from Patient Elopement Cases
DescriptionPatient elopement, defined as an event in which a patient leaves a healthcare setting without staff awareness or authorization, poses serious safety risks. Patients who elope may be medically unstable, cognitively impaired or at risk to their own safety leading to consequences that include injury, delayed treatment, and in some cases, death. Beyond clinical risks, patient elopements can also create reputational, legal, and financial harm for hospitals. Yet compared to other patient safety events such as falls or medication errors, elopement often receives less systematic attention.
Traditional incident reviews remain a critical tool for responding to elopement events. At our acute care hospital in Toronto, Canada, each critical incident undergoes structured review with frontline staff and operational leaders, generating timely, event-specific recommendations. This approach is operationally resource-manageable, fosters stakeholder engagement, and ensures that immediate contributing factors revealed by the incident can be addressed in a timely manner. However, multiple elopement incidences from a single inpatient unit, each with varied characteristics, signaled that broader systemic factors were also influencing outcomes.
Recognizing this, the Human Factors and Quality Improvement teams partnered to apply a sociotechnical approach to understand the broader systemic contributors to elopement. This assessment, guided by the Systems Engineering Initiative for Patient Safety (SEIPS) model, extended beyond the review of single events on a single unit to consider system-level patient elopement risks across the multiple units that shared the same open physical space. Methods included: in-situ observations and interviews of relevant stakeholders, task and workflow analysis, environmental walkthroughs, technology review, staff survey data, application of the COM-B model to explore behavioural drivers, and a retrospective 18-month review of incident data.
This systemic analysis revealed gaps that individual reviews alone had not surfaced, such as inconsistent application of risk assessments, physical layouts that compromised monitoring of exits, and misalignment between monitoring technology design and actual staff use. Findings informed both proactive measures (standardized risk identification, improved environmental monitoring) and reactive measures (multi-level alarm-based detection and response), prioritized using the hierarchy of intervention effectiveness to emphasize system-level solutions over reliance on vigilance.
By blending incident-level and system-level approaches, this work highlights the distinct benefits of “zooming in” to review individual incidents and “zooming out” to assess systemic contributors. Incident reviews remain indispensable for rapid, resource-efficient identification of immediate contributing factors, while systemic reviews are warranted when patterns repeat or when incidents involve complex interactions across tools, workflows, and environments. Together, they provide a balanced strategy for generating both actionable and sustainable improvements to patient safety that is operationally sustainable.
Traditional incident reviews remain a critical tool for responding to elopement events. At our acute care hospital in Toronto, Canada, each critical incident undergoes structured review with frontline staff and operational leaders, generating timely, event-specific recommendations. This approach is operationally resource-manageable, fosters stakeholder engagement, and ensures that immediate contributing factors revealed by the incident can be addressed in a timely manner. However, multiple elopement incidences from a single inpatient unit, each with varied characteristics, signaled that broader systemic factors were also influencing outcomes.
Recognizing this, the Human Factors and Quality Improvement teams partnered to apply a sociotechnical approach to understand the broader systemic contributors to elopement. This assessment, guided by the Systems Engineering Initiative for Patient Safety (SEIPS) model, extended beyond the review of single events on a single unit to consider system-level patient elopement risks across the multiple units that shared the same open physical space. Methods included: in-situ observations and interviews of relevant stakeholders, task and workflow analysis, environmental walkthroughs, technology review, staff survey data, application of the COM-B model to explore behavioural drivers, and a retrospective 18-month review of incident data.
This systemic analysis revealed gaps that individual reviews alone had not surfaced, such as inconsistent application of risk assessments, physical layouts that compromised monitoring of exits, and misalignment between monitoring technology design and actual staff use. Findings informed both proactive measures (standardized risk identification, improved environmental monitoring) and reactive measures (multi-level alarm-based detection and response), prioritized using the hierarchy of intervention effectiveness to emphasize system-level solutions over reliance on vigilance.
By blending incident-level and system-level approaches, this work highlights the distinct benefits of “zooming in” to review individual incidents and “zooming out” to assess systemic contributors. Incident reviews remain indispensable for rapid, resource-efficient identification of immediate contributing factors, while systemic reviews are warranted when patterns repeat or when incidents involve complex interactions across tools, workflows, and environments. Together, they provide a balanced strategy for generating both actionable and sustainable improvements to patient safety that is operationally sustainable.
Event Type
Oral Presentations
TimeTuesday, March 244:10pm - 4:30pm EDT
LocationMurray Hill East
Patient Safety Research and Initiatives