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Ticket to Ride: Reducing Handoff Risk During Hospital Patient Transport

Pesanka, Deborah A. MS, RN; Greenhouse, Pamela K. MBA; Rack, Laurie L. MSN, RN; Delucia, Gail A. BSN, RN; Perret, Robert W.; Scholle, Carol C. MSN, RN; Johnson, Marlon S. RN; Janov, Cheryl L. BSN, RN

doi: 10.1097/01.NCQ.0000347446.98299.b5

A significant number of medical errors occur during patient handoffs, leading to less than optimal care, patient harm, and even death. The Joint Commission National Patient Safety Goals require hospitals to implement a standardized approach to “handoff” communications. The authors describe an initiative that focuses on standardization of the physical and informational handoff during hospital transport; outcomes are promising in terms of both patient safety and patient satisfaction.

UPMC Center for Quality Improvement and Innovation (Mss Pesanka and Greenhouse) and UPMC Presbyterian (Mss Rack, Delucia, Scholle, Johnson, and Janov, and Mr Perret), Pittsburgh, Pennsylvania.

Corresponding Author: Pamela K. Greenhouse, MBA, UPMC Center for Quality Improvement and Innovation, 4601 Baum Blvd, Pittsburgh, PA 15213 (

Accepted for publication: July 23, 2008

© 2009 Lippincott Williams & Wilkins, Inc.