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  1. Ray, Leslie N. RN, PhD

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JOHN GREEN, 45, hospitalized with abdominal pain, has a history of anaphylaxis to latex. His nurses identified his latex allergy, placed an allergy band on his wrist to alert healthcare providers, and instituted latex precautions to prevent contact with latex-containing materials. Two days into his hospital stay, Mr. Green was sent to another department for a diagnostic study. Staff in this department, having no clinical information about the patient other than his possible diagnosis and his scheduled procedure, performed the study using vials and syringes containing latex. Mr. Green experienced latex-induced anaphylaxis, requiring aggressive support of airway, oxygenation, ventilation, and circulation.


This hypothetical case, based on an incident reported by the Institute for Safe Medication Practices, clearly demonstrates why patient information must be accurately conveyed at all stages in a patient's care.1 Gaps and inaccuracies in shared information frequently contribute to potentially serious adverse events.


The Joint Commission (TJC) and the National Quality Forum endorse giving appropriate, timely, and accurate information to all healthcare providers and facilities involved in a patient's care. To prevent communication breakdowns, structured handoffs are an essential safeguard as outlined in National Patient Safety Goal This article describes a concise handoff tool, the Ticket to Ride, which helps maintain patient safety and continuity of care when patients temporarily leave their unit. (See Do you have a Ticket to Ride?)


What's a handoff?

A handoff or handover is the transfer of responsibility for care from one healthcare professional to another. Longer term handoffs include those between physicians when on-call status changes. Temporary handoffs include nursing coverage for patients when their nurse is away from the unit.


A special type of handoff occurs when a patient like Mr. Green temporarily leaves the unit and the staff responsible for his care, usually for diagnostic testing or therapy. These situations don't clearly fall under TJC's definition of a handoff because the responsibility for patient care isn't being transferred to another healthcare professional and the person most directly involved is the transporter.


When care isn't transferred but a patient is away from those most directly responsible for his care, such as when he leaves the unit for diagnostic testing or therapy, critical information must go with him. This also requires a standardized way to communicate.


One of the best-known tools for handoffs is SBAR (Situation-Background-Assessment-Recommendation). Although any handoff tool can be modified to fit specific situations, they're intended for transferring responsibility for care. In contrast, a patient leaving the unit temporarily needs a Ticket to Ride.


Getting a Ticket to Ride

The Ticket to Ride is becoming increasingly popular as a patient-safety tool. Doctors Hospital in Coral Gables, Fla., uses a Ticket to Ride each time a patient leaves the unit temporarily or is transferred to another unit.3 The nurse caring for the patient can complete the short document quickly to ensure that transporters and providers unfamiliar with the patient will have important information readily available if problems arise or the patient is away from the unit longer than expected. Another benefit noted by the staff at Doctors Hospital is the increased sense of teamwork achieved by including transporters on the team.


The one-page document must be easy to read and identify important aspects of patient care. Although the ticket's content can vary somewhat among hospitals, it should always include the name of the RN responsible for the patient and a phone number for questions or problems. Also include this information about the patient:


* allergies


* fall risk


* sensory impairment


* recent pain or sleep medications


* time-sensitive treatments


* special needs such as supplemental oxygen.



Consider including information about the patient's mental status and any language difficulties. The document can also provide a space to add information about the patient's experience during the procedure or test that his nurse would need to know; for instance, if staff had difficulty starting an I.V. or if he experienced new signs or symptoms.


Designing your own Ticket to Ride

To develop a Ticket to Ride that suits your facility, staff, and patient population, consider who, what, where, when, and how:


* Who initiates the ticket-transporter or the unit RN? Who completes it?


* What information needs to be on the ticket? What's not useful or critical information?


* Where does the ticket reside after it's completed, during transport, and after the patient returns to the unit?


* When should the ticket be used-whenever the patient changes location, only for some changes, or only for temporary changes in location?


* How does the ticket fit with existing patient documents and any electronic health records?



Follow a plan to work out the details

Because each unit in the hospital may have its own preferred answers to these questions, creating a useful facility-wide ticket can present a challenge. One approach that works well is using PDSA (Plan-Do-Study-Act), as advocated by the Institute for Healthcare Improvement, for testing small steps of change.4 This straightforward process checks to see if the proposed change is workable. Revisions can be made quickly and problems corrected before the hospital commits to implementing it throughout the facility.


Using PDSA, you can get input from staff and develop a preliminary ticket relatively quickly (Plan). Then test it with one nurse, one patient, and one transporter (Do). Use reactions and feedback from those involved to make changes (Study). As the next step, roll out the modified tool on a single shift in a single unit (Act). Continue the cycle one or two more times as needed until the Ticket to Ride is ready for rollout throughout the hospital.


Filling the gap

The Ticket to Ride is a promising tool for hospitals to add to their patient-safety toolkit. It fills a gap by allowing vital information to be shared when the patient leaves the unit temporarily.




1. Confusion over meaning of color-coded wristbands. ISMP Newsletter. March 9, 2006. http://www.ismp.org/Newsletters/acutecare/articles/20060309_3.asp. [Context Link]


2. The Joint Commission. 2009 National Patient Safety Goals. http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/09_hap_n. [Context Link]


3. Patients at this hospital have a "ticket to ride." Healthcare Benchmarks Qual Improv. 2006;13(9): 102-104. [Context Link]


4. Institute of Healthcare Improvement: Testing changes. http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/testin. [Context Link]