Clinical Care

How a responsible event report improved our practices

Finding the gaps in our processes can help us fill them.


Asante’s Intra-Hospital Transfer or Transport of Patients policy (400-PCS-NURS-0953) was recently updated due to key learnings from an event report. The purpose of this policy is to support frontline staff in understanding the requirements and procedures to transfer patients safely throughout the hospital. The revised policy also includes guidelines for baseline staff and what equipment is needed to safely transport patients in relation to their clinical condition.

Case study

Nearing a change of shift, a patient we’ll call Mrs. Smith was transported to another area of the hospital for a test. During her hospital stay, Mrs. Smith was noted to have some confusion and displayed signs of delirium. She was also a high fall risk.

Mrs. Smith’s confusion was not obvious to the care team during the test, and there was no clarity about who would transport Mrs. Smith back to her room after the test. The team that performed the test stepped away to finalize their documentation.

Left alone, Mrs. Smith stood up and began to wander around the hospital by herself. She was found pushing her wheelchair down an empty hallway with her gown loose. Thankfully, Mrs. Smith was unharmed. During the investigation it was learned that transport was delayed due to another critical patient situation and was unable to communicate the delay.

This event prompted Asante to update the Intra-Hospital Transfer or Transport of Patients policy to include critical language about supporting confused or delirious patients to ensure patient safety. Here are some of the changes.

Prior to transfer or transport: Communicate with the receiving location any concerns for instability or monitoring needs.

During transfer or transport: Communicate with transport team any specific considerations regarding instability or monitoring needs. This includes the patient’s level of orientation or risk of confusion. In some cases, an RN must accompany the patient. See appendix A of the revised policy for details.

Returning transfer or transport: Patients with instability or confusion should never be left alone. Refer to appendix A on who can safely transport patients.

Please take a moment to review 400-PCS-NURS-0953 Intra-Hospital Transfer or Transport of Patients to ensure safety for our staff and patients.

Thank you to the care team members who reported this incident. Reporting events helps us learn and grow as an organization.

Tags: Holly Nickerson, policy, RER, STAT, transport
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