University of Pittsburgh Medical Center executives yesterday announced a system-wide safety reform spurred by the case of a dementia patient who wandered away from her room and was found dead 14 hours later on the hospital rooftop.

They call their new system "Condition L," and said it would improve hospital searches the way Amber Alerts has in cases of missing children.

"We're learning from what has been a tragedy," said Tami Merryman, UPMC's chief quality officer.

UPMC revamped its search policies because of the death of Rose Lee Diggs, who walked away from her 12th-floor room in UPMC Montefiore about 5:15 p.m. Dec. 2. A hospital maintenance worker found Mrs. Diggs' body on the roof, one floor above her room, just before 8 a.m. Dec. 3.

The Allegheny County medical examiner yesterday said an autopsy on Mrs. Diggs was complete, but the cause and manner of her death were still listed as "pending."

Mrs. Diggs was found in her hospital gown and slippers after a night in which temperatures fell to the 20s. Still unclear to the hospital staff was how long she was in the cold.

UPMC employees checked the roof two other times during their search but found no sign of Mrs. Diggs, Ms. Merryman said. Mrs. Diggs may have wandered through other parts of the hospital before going outside.

At age 89, she was mobile enough to walk down the hall and out an unlocked "fire door" used as an exit from the floor. After that, her movements went undetected, even as employees numbering in the "dozens" searched for her, said Holly Lorenz, chief nursing officer and vice president of patient care services at UPMC Presbyterian Shadyside.

She said instances of patients walking away were rare, but the new system will provide hospital staffs with an improved method for finding those who wander.

If a patient is missing, Condition L will be initiated by a nurse on the unit and announced throughout the hospital. A description of the missing patient will be provided, and the hospital staff will continue its practice of immediately notifying police.

Then every available UPMC employee, including those in security, nursing, maintenance and housekeeping, would join in a coordinated search of the hospital complex.

Rob Pierce III, an attorney for Mrs. Diggs' estate, said he was glad that UPMC had created a plan to improve patient safety.

"However, I still fail to understand why this procedure wasn't in effect already. Had that been the case, Mrs. Diggs could be enjoying the holidays with her family," he said.

Lois Lutz, education and outreach coordinator of the Greater Pennsylvania Chapter of the Alzheimer's Association, said hospitals might best combat wandering by placing electronic bracelets on the wrist or ankle of dementia patients.

"I would think it would be something easy to implement. They already do it in hospitals when a baby is born," she said.

Ms. Merryman said UPMC was exploring just such an electronic monitoring system for dementia patients.

UPMC also is looking at the possibility of using tracking dogs to help in searches if a patient walks away.

In addition to Condition L, UPMC executives said other changes would be made to prevent a repeat of Mrs. Diggs' case.

Geriatric or psychiatric nurses will assess certain patients to identify those most at risk of wandering. Then individual plans for their care will be developed.

Another change involves UPMC security and maintenance workers, who are collaborating to inspect doors leading to roofs and mechanical areas.

"Hindsight is always 20-20," Ms. Merryman said of criticism that UPMC was not vigilant enough in searching for Mrs. Diggs. "We are learning from what happened and implementing changes."