Use of a Standardized Handoff Tool to Prevent Oxygen-Related Adverse Events for Emergency Department Patients Being Transported to Diagnostic Imaging

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Publication Date

7-15-2026

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Presentation: 43:52

Abstract

Accurate handoff communication during care transitions is imperative to maintaining the safety of patients as incomplete, inaccurate, or omitted handoffs have the potential to cause harm, injury or even death. Despite regulatory requirements for standardized handoff communication, these events continue to occur. While regulatory agencies are not prescriptive as to type or method of handoff is used, one of the commonly employed tools is a “ticket-to-ride”. After experiencing empty oxygen tank related patient safety events, the organization conducted root cause analyses and evaluated departmental flow and work systems and processes to determine how best to keep traveling patients safe. It was determined that implementing a ticket to ride for patients on oxygen who left the emergency department for diagnostic imaging and returned to the department following these tests would be the most feasible course of action and, after its development, it was educated to staff using the PDSA model for improvement. Multiple PDSA cycles were required during the process as feedback and new equipment were presented, however, over the course of one year, the communication tool was seen to be well imbedded in current departmental practices. This success is evident when reviewing audit reports demonstrating high levels of compliance on completion of the ticket to ride as well as the department not having experienced an oxygen-related safety event in 7 months. It is recognized, however, that under-reporting of patient safety events is a common concern in healthcare, so events may have occurred that were not brought forth.

Language

English

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