Jane, a six-year-old girl, underwent an operation for a congenital heart defect. The operation went smoothly, but the transfer between the recovery suite and the care unit did not go as well as it might have done and the patient went into cardiac arrest upon arrival at the care unit. Analysis of this adverse event resulted in a number of recommendations: assess the patient’s clinical severity ahead of transfer to determine the profile required for the transfer team; assess the patient following transfer to detect any changes in the patient’s state of health; develop and implement an in-house checklist for transfers; use standardised communication tools; and promote a safety culture, specifically through use of the Speak-Up model.
Date de parution : 06/2019
Thème : Inpatient transfer
Mots clés : communication, checklist, SBAR
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