SHM Converge Scientific Abstract ePoster Gallery-A Ticket to Ride: Improving Patient Safety During Hospital Transport

Pdf Summary

This quality improvement project addressed communication failures during intrahospital patient transport, a known source of preventable harm. At a quaternary academic medical center, a Medicine Step Down Unit had experienced two adverse events related to transport, prompting the team to create a standardized handoff tool called a “Ticket-to-Ride.”<br /><br />The ticket was designed by staff and leadership and used a Situation-Background-Assessment-Recommendation (SBAR) format. It included key details such as patient demographics, transport destination, safety concerns, and whether clinical personnel needed to accompany the patient. Bedside nurses completed the ticket, which was then placed in the patient’s physical chart to travel with the patient.<br /><br />From December 2023 through September 2024, the unit recorded 1,146 transport events, with 457 completed tickets, for a completion rate of 39.9%. Completion varied by month, ranging from 27.5% to 55.5%. Despite incomplete uptake, safety review found no related adverse events during transport in the study period. A post-intervention survey completed by 26 nurses showed strong awareness of the project, with most respondents understanding its goals and believing it improved safety. However, only 61.5% felt they had received adequate training.<br /><br />The project suggests that a structured transport handoff tool may improve patient safety, even if implementation is imperfect. The authors identified barriers such as workload, familiarity of floating nurses with the process, and insufficient training. Future plans include more staff education and integrating the Ticket-to-Ride into the electronic medical record.

Asset Subtitle

Giuseppe A. Fiorica

Meta Tag

Author List Giuseppe A. Fiorica, Michael Herscher, Vinh-Tung P. Nguyen

Category Innovations

Concept Handoff Tool

Concept Transport Ticket

Concept Intrahospital Patient Transport

Concept Patient Safety

Concept SBAR

Distinguished Non-Finalist

Presenter Organization Mount Sinai Hospital

Presenting Author Giuseppe A. Fiorica

Track Quality Improvement

Keywords

patient transport

handoff tool

SBAR

patient safety

quality improvement

intrahospital transport

adverse events

nursing communication

medicine step down unit

electronic medical record

Handoff Tool

Transport Ticket

Intrahospital Patient Transport

Patient Safety

SBAR