Quality and Safety Exemplar

This quality and safety issue breakdown began from a serious safety event (SSE) occurring from the absence of monitoring while a patient was off their home unit for diagnostic testing. For this SSE, I lead an interprofessional team of content experts to determine root cause and to develop a hospital wide solution to prevent these types of events from occurring again.  DNP Essential VI which involves the interprofessional collaboration for improving patient and population health outcomes applies to this quality and safety issue. The team discovered the root cause stemming from a transportation order placed for cardiac monitoring removal to prevent the delay of the diagnostic test.

Most of the literature which exists on patient transportation involves intensive care or pediatric patients. The Pennsylvania Patient Safety Reporting System published the most beneficial resource regarding safe transport of the non-ICU patient; which focused on handoff communication and transportation teams (Huber, 2010).

Huber C. (2010). Safe intrahospital transport of non-ICU patients. The American journal of

nursing110(11), 66–69. https://doi-org./10.1097/01.NAJ.0000390531.14314.1c


  1. Tiffany Lord

    Thank you for leading this important initiative. As nurses, we are masterminds at creating workarounds to problems instead of addressing the issue head-on. Our unit would routinely grapple with transporting a patient on a cardiac monitor when they really might not need it. As a result, there would be a lot of order shuffling to get the patient to their procedure without the monitor and then back on the monitor upon returning to the unit. None of this made great sense and really was a matter of time until something negative occurred. Your involvement and work on this safety event are appreciated by staff and patients. Great job highlighted and solving an important issue.

  2. giscombeny

    Thanks for sharing your experience conducting this valuable review and exploration of safety event. This scenario you describe has been of great debate even since i was an ICU and Med-Surg nurse back in the 80-90s. It sad to hear that not much has changed. Nevertheless, i am optimistic that as we prepare more advanced nurse leaders and DNP change agents risk such as patient transportation will be address, mitigating efforts and EBP policies implemented to improve quality and patient safety. Great job in leading this effort.

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