Risk Management Tools & Resources


CASE STUDY: Lapses in Elopement Policies Have Grave Consequences for Behavioral Health Patient

Laura M. Cascella, MA

CASE STUDY: Lapses in Elopement Policies Have Grave Consequences for Behavioral Health Patient


The patient was a 20-year-old male with behavioral health issues who had multiple prior admissions to a hospital psychiatric unit over a 6-year span. On October 10, he was admitted to the psychiatric unit again through the emergency department (ED) for emergency detention. Upon arrival, the patient was having a psychotic episode (hallucinations and paranoia), but after 14 hours of sleep, he appeared calm and engaged. A nurse screened the patient for suicidal ideation and classified him as low risk. Because he had tried to leave the ED the previous day, the patient was placed on elopement precaution.

Over the next several days, the patient attended group therapy, was more social, and was noted by nursing staff to be doing better than he had on previous admissions. On October 15, the attending psychiatrist lifted the elopement precaution. The next day, the patient’s mother visited, and the patient stated that he wanted to go off the unit for a while. Because he was no longer on elopement precaution, the patient was allowed to leave the unit under his mother’s supervision, and they went to a gated outdoor patio at the hospital.

During that time, the mother received a call on her cellphone and proceeded to step away from the patient to have a brief discussion. The patient walked back into the hospital and then eloped from the main entrance, as video surveillance later showed. The patient’s mother spent about 15 minutes looking for him and then returned to the psychiatric unit to report that the patient was missing. She did not mention to staff that she had already spent time looking for him.

Several staff members then went to look for the patient (it was not known at that point that he had left through the main entrance); when he wasn’t found, staff alerted security. The patient’s mother told security that she wasn’t overly concerned because she felt the patient was doing well and had either gone home or would return shortly. Eventually, the police were alerted, but it is unclear how much time passed between the patient eloping and notification to law enforcement.

Approximately 10 hours later, the patient was killed when he ran across a busy road and was hit by a motor vehicle. A postmortem toxicology report showed the patient had alcohol and marijuana in his system. The patient’s family filed a lawsuit against the hospital alleging failure to appropriately monitor the patient and failure to prevent elopement. The case was settled with a payment in the mid-range.


Elopement is an ongoing concern in healthcare facilities for various types of patients, but particularly for behavioral health patients who might be at risk of harming themselves or others, becoming disoriented, or being unable to meet their basic needs. Not all behavioral health patients are at risk of eloping, but the consequences for those who do elope can be significant and devastating.

Many resources on elopement focus on environmental safeguards, such as establishing elopement buffers and barriers to prevent patients from leaving EDs and behavioral health units. This case involves issues related to physical safeguards, but also presents other contributing factors to elopement, notably inadequate elopement policies, communication lapses, and failure to follow protocols.

The patient in this case did not elope in a dramatic or subversive fashion. He did not tailgate staff through a door, climb a wall, or breach a barrier — he merely walked out of the hospital’s front entrance. Although his mother’s distraction from a phone call contributed to the patient’s ability to slip away unnoticed, other factors leading up to the incident also created an opportunity for the patient to elope.

The first issue was the hospital’s elopement policy. Although the patient was initially placed on elopement precaution, the attending psychiatrist removed the precaution after only several days. The patient was noted to be more alert and social; however, he also had tried to elope from the ED only a few days before, and he had a prior history of elopement attempts from the behavioral health unit during previous admissions.

Experts involved in the case questioned the psychiatrist’s decision to remove the elopement precaution based on the patient’s history and his behavioral health issues and symptoms (hallucinations and paranoia). Additionally, it was determined that the organization did not have standard protocols for placing patients on, or removing patients from, elopement precaution. As a result, the defense could not point to a consistent process or set of criteria that justified the psychiatrist’s decision other than his own clinical judgment. Further complicating the situation was the fact that the psychiatrist did not document his rationale for removing the elopement precaution.

A second issue in this case was allowing the patient to visit an outdoor area under the supervision of only his mother. Although it is not uncommon for hospitals to allow behavioral health patients who are not at risk of elopement to visit a recreational area, such as an outdoor patio or garden, it is imperative that proper security and oversight are in place. Although the outdoor patio at this hospital was gated, the patient was still able to easily return to the building and exit through the main entrance while his mother was busy on the phone.

To avoid this type of scenario, healthcare organizations need to consider (a) physical safeguards that create barriers, checkpoints, or other types of alerts to decrease the likelihood of elopement; (b) monitoring protocols for patients who are allowed to leave the behavioral health unit (e.g., whether they may leave alone or with family members, or whether they require an designated escort); and (c) appropriate education for visitors who assume responsibility for overseeing patient visits to recreational areas.

In this case, the patient’s mother did not receive any specific education or guidance about supervising the patient when he left the behavioral health unit or what to do if he attempted or succeeded in eloping. As a result, she spent 15 minutes looking for him on her own and then failed to report that search time to staff members when she notified them about the patient’s disappearance.

Another issue occurred when the staff on the behavioral health unit did not follow organizational policy for responding to an elopement, which specified that hospital security should be notified immediately and designated staff should search the premises. Rather, the staff members initiated the search, but delayed reporting the incident to security. Because of lack of documentation, it also is not clear how long it took security to report the missing patient to law enforcement and how much time elapsed between the patient leaving the hospital and law enforcement starting a search. What is clear, however, is that failure to follow the established protocol resulted in the loss of valuable time and potentially the opportunity to locate the patient before he was harmed.

Risk Strategies

The Agency for Healthcare Research and Quality notes that breakdowns in patient assessment and team communication are top contributing factors in elopement.1 To proactively address elopement risks and take steps to avoid a situation similar to what occurred in this case, healthcare organizations should develop well-defined policies and procedures and a systems-wide approach for preventing and responding to elopement.

Organizational leaders, healthcare providers, and staff members should consider the following risk strategies when reviewing their elopement protocols:

  • Conduct a risk assessment for each patient upon admission and periodically throughout the patient’s admission to determine elopement risk.
  • Use consistent criteria when assessing patients for elopement risk; criteria should take into account factors such as the patient’s mobility, mental status, observed behaviors and statements, and potential elopement risks (e.g., previous elopement attempts, dementia, psychotic episodes, and alcohol or drug withdrawal).
  • Consider using a decision-making tool or aid to facilitate elopement assessments, such as a decision tree or checklist.
  • Thoroughly document all elopement assessments and their outcomes (e.g., if a patient is placed on elopement precaution or if an elopement precaution is removed) and the rationale and decision-making process.
  • Implement diversionary activities to prevent elopement. Common reasons for elopement include being bored, feeling trapped, missing family/friends, and feeling neglected.2 Activities that engage patients and encourage social interaction — such as movies, physical activities, hobbies, pet therapy, reading, social visits, etc. — can help address these feelings.
  • Use environmental safeguards to prevent elopement, such as door alarms, door/window locks, video cameras, and patient tracking devices.
  • Develop an incident response policy and procedure that staff members can quickly activate if a patient knowingly elopes or goes missing. The policy should include detailed information about what steps staff members should take, the appropriate sequence of steps, staff accountabilities, communication requirements, and appropriate contact information.
  • Develop a procedure for analyzing all elopements and elopement attempts. Designate appropriate staff to review incidents and provide follow-up.
  • Educate providers and staff about preventing and responding to patient elopements, including risk factors, accountabilities, and critical action steps.



1 Agency for Healthcare Research and Quality. (2007, December). Patient Safety Network cases & commentaries: Elopement. Retrieved from https://psnet.ahrq.gov/webmm/case/164

2 Brumbles, D., & Meister, A. (2013). Psychiatric elopement: Using evidence to examine causative factors and preventative measures. Archives of Psychiatric Nursing, 27(1), 3–9. doi: 10.1016/j.apnu.2012.07.002

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