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UPMC Creates ‘Condition L’ Safety Procedure to Rapidly Find Missing Patients

PITTSBURGH, December 30, 2008 — In its latest enhancement to patient safety, UPMC today announced the creation of a procedure to rapidly locate missing patients. Modeled after other rapid response teams used in hospital emergencies, Condition L will mobilize hospital staff from across the facility for a comprehensive, systematic search in the rare cases when patients wander away from their units.

“Our goal in quickly implementing these changes is to ensure the safest environment possible for our patients and to improve our response when patients inadvertently wander away from direct supervision,” said Holly Lorenz, chief nursing officer and vice president of patient care services, UPMC Presbyterian Shadyside. Condition L will first be adopted by the UPMC Presbyterian campus and then rolled out systemwide.

Similar to existing medical emergency codes within the hospital, Condition L will be initiated by a nurse on the unit and announced overhead throughout the hospital complex by the hospital operator, who also will provide a description of the patient. Consistent with previous practice, the hospital will immediately notify local police.

Condition L summons and utilizes every available staff member including security, nursing, maintenance and housekeeping to assist in a coordinated search of the hospital complex. “Our goal is the safe and quick return of the patient to the unit,” noted Ms. Lorenz. UPMC also is evaluating the use of trained search dogs to assist, if necessary.

Additionally, with patient or family permission, photos will be taken of at-risk patients upon admission. In the event of Condition L activation, the patient’s photo and descriptive information will be distributed by email throughout the complex. Patients identified as at-risk for wandering will wear distinctively colored hospital gowns to make them easier to identify if they leave the unit.

Condition L was created in the aftermath of the death of Rose Lee Diggs, who suffered from dementia, after she wandered away from her room in UPMC Montefiore and onto the roof in early December.

”We are applying the lessons learned in this incident to improve the safety of our most vulnerable patients,” said Tami Merryman, UPMC’s chief quality officer. UPMC has a long track record of adopting innovative safety practices, noted Ms. Merryman. For instance, the health system was the first in the nation to allow patients and their families to summon a rapid response team to the bedside for any concerns related to a patient’s care 

In addition to Condition L, UPMC is implementing additional safety measures to prevent another such tragedy. Specifically, certain patients will be thoroughly assessed by geriatric or psychiatric nurses to identify those most at risk for wandering from their rooms. Following the assessment, individualized patient care plans will be developed and specific interventions used.

Signage has been placed on all mechanical room doors indicating they must remain locked, and security and maintenance personnel are collaborating to inspect door locks leading into mechanical areas and roofs on a daily basis. An enhanced maintenance program has been established for mechanical door testing.

“Providing the highest quality care to our patients in a safe environment is our top priority,” said Ms. Merryman. “With these new safety measures, we underscore our commitment to the constant vigilance and continuous improvement needed to protect all of our patients.”

UPMC is an integrated global health enterprise headquartered in Pittsburgh, Pennsylvania, and one of the leading nonprofit health systems in the United States. As western Pennsylvania’s largest employer, with 50,000 employees and $7 billion in revenue, UPMC is transforming the economy of the region into one based on medicine, research and technology. By integrating 20 hospitals, 400 doctors’ offices and outpatient sites, long-term care facilities and a major health insurance services division, and in collaboration with its academic partner, the University of Pittsburgh Schools of the Health Sciences, UPMC has advanced the quality and efficiency of health care and developed internationally renowned programs in transplantation, cancer, neurosurgery, psychiatry, orthopaedics and sports medicine, among others. UPMC is commercializing its medical and technological expertise by nurturing new companies, developing strategic business relationships with some of the world’s leading multinational corporations and expanding into international markets, including Italy, Ireland, the United Kingdom and Qatar. For more information about UPMC, visit our website at

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