SHM Converge Scientific Abstract ePoster Gallery-Improving Patient Safety During Off Campus Diagnostic Testing

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This document describes a quality improvement project at Mass General Brigham’s Faulkner Hospital (BWFH) and Brigham and Women’s Hospital (BWH) aimed at improving patient safety during off-campus Leave of Absence (LOA) transfers for advanced diagnostic testing and procedures.<br /><br />BWFH is a 171-bed community hospital that relies on BWH for specialized services. Patients are transported to BWH for tests or procedures and then returned to BWFH. Although this process supports access to tertiary care, several safety concerns were identified, including poor communication, inadequate nursing support, lack of an on-campus clinician, medication access problems, and delayed transport back to BWFH.<br /><br />The project evaluated the existing LOA process by reviewing patient safety reports, adverse event reports, patient/family concerns, provider interviews, and LOA volume by destination and procedure. Interviews were conducted across all involved departments at both hospitals, including interventional radiology, diagnostic imaging, interventional cardiology, gastroenterology, and cardiac testing.<br /><br />Two example cases illustrated risks: one patient with high-risk telemetry was sent to BWH for cardiac MRI without the receiving team knowing she required nursing monitoring; another patient with diabetes experienced prolonged delay returning to BWFH and lacked access to glucose monitoring, insulin, meals, or active clinical oversight while at BWH.<br /><br />Based on these findings, best practices were adapted from high-performing departments and a multidisciplinary team from both campuses developed a pre-LOA safety checklist. The new workflow also clarified expectations for MD, APP, and RN support when needed and included EMR updates to support order entry and communication. Easy access to department-specific transfer algorithms and contact information was also recommended.<br /><br />Key findings showed that 7% of LOAs had safety reports, and 89% of these were related to care coordination. The project concludes that LOA can improve access to care but requires stronger screening, communication, and coordination to reduce safety risks. Continued monitoring and staff education were identified as next steps.

Asset Subtitle

Erin C. O'Fallon

Meta Tag

Author List Caitlin Manca, Erin C. O'Fallon, Johanna Baldassari

Category Innovations

Concept Leave of Absence

Concept Patient Safety

Concept Communication Gap

Concept Handoff

Concept Pre-LOA Screening Checklist

Distinguished Non-Finalist

Presenter Organization Brigham and Womens Hospital

Presenting Author Erin C. O'Fallon

Track Patient Safety

Keywords

patient safety

leave of absence

care coordination

hospital transfer

quality improvement

communication

nursing support

multidisciplinary team

advanced diagnostic testing

pre-LOA safety checklist

Leave of Absence

Patient Safety

Communication Gap

Handoff

Pre-LOA Screening Checklist