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Check Twice, Transport Once

Alexandria DePew, MSN, RN, James Rice, & Julie Chou, BSN | May 16, 2022
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The Case

Case #1: A 26-year-old woman (Patient A) presented to the Emergency Department (ED) with abdominal pain and was diagnosed with “suspected ruptured ectopic pregnancy with hemoperitoneum.” She was scheduled for urgent laparoscopic left salpingectomy in the main operating room (OR). Due to the urgency of the surgery, it was agreed by the ED and the OR charge nurse that the patient would be transported directly to the OR by the anesthesia care provider. The OR circulating nurse was unable to complete a full pre-operative interview. A second patient (Patient B) was a 54-year-old woman who presented to the ED the same evening with abdominal pain and bleeding from her stoma site and was scheduled for esophagogastroduodenoscopy (EGD) in the Gastrointestinal (GI) lab. Both patients had patient identifier wrist bands and were consented for their appropriate procedures. Patient B was transported directly from the ED to the OR instead of to the GI lab. The circulating nurse in the OR caught the error during the pre-procedure huddle and discovered that Patient B was not the correct patient. Patient B was transported back to the ED to await their GI lab procedure and Patient A was brought to the OR. The OR team completed the pre-procedure huddle, but during their check for availability of blood products, it was unclear whether blood type verification had been drawn on the correct patient in the ED, so another blood specimen was obtained, and uncrossed blood was sent for Patient A.

Case #2: A 36-year-old woman (Patient C), who was nine weeks pregnant, presented to the ED with nausea and vomiting, abdominal pain, and volume depletion. An intravenous (IV) line was placed to administer fluid. The obstetrics and gynecology (OB/GYN) team ordered a bedside ultrasound to rule out appendicitis versus miscarriage. Another patient (Patient D) was a 30-year-old woman with a history of asthma who presented to the ED at the same time with cough, wheezing, and chest discomfort. A chest x-ray was ordered for Patient D. Patient C was transported to Radiology by mistake and received the x-ray ordered for Patient D. 

The Commentary

By Alexandria DePew, MSN, RN, James Rice, & Julie Chou, BSN


Emergency departments across the nation face high volumes, overcrowding, and rapid turnover of acutely ill patients who require high-risk processes and procedures. As a result, significant emphasis is placed on patient throughput and maximizing flow.1 As patients are moved through the ED to be triaged and treated based on their initial presentation, they are often transported to alternate locations to obtain additional technical, cognitive, or procedural care while awaiting inpatient admission.2 This dynamic movement and transportation of ED patients within the department, to adjacent units (e.g., radiology), and within the hospital (e.g., inpatient units, the operating room, etc.) creates an environment prone to error.

Incidence of intrahospital patient transport errors varies across settings, patient populations, reporting methods, and definitions. While a six-year retrospective study from Taiwan estimated the incidence of patient safety events associated with intrahospital transport at 102.5 per 1,000,000 sessions2,estimates in critically ill patient populations and published quality improvement initiatives on reducing transport errors report higher rates.3-4 Variation in existing literature may be attributed to differing definitions of what constitutes an adverse event and transport of critically ill adult and pediatric patients, who are at higher risk for physiological deterioration during transport.

Throughout the hospital, there can be variability in how patients are transported, which is often dictated by the patient’s acuity, as well as resource allocation. Registered nurses (RNs), ED technicians, OR staff, and patient transport staff all have the capacity and scope to transport patients, but staff in different roles or groups may not follow the same practices. While each role is expected to verify patient identifiers before transporting patients, departments may utilize different methods, including automated systems or enhanced technology, to support patient safety.

In the cases described above, the incorrect patient was transported for a procedure or surgery, which led to incorrect interventions being performed and delays in care. Errors in patient transport are often attributed to a lack of standardized processes, variability in practice, and/or lack of communication surrounding transportation, either pre-, intra-, or post-transportation.2,4 Errors involving communication can include a lack of a report or handoff, or an incorrect report or handoff between staff, and can result in errors such as missed or delayed medication administration or orders.5 Such medication, treatment, and equipment errors can have potentially grave consequences affecting both patient outcomes and healthcare costs.

Other types of errors involving patient transport include equipment malfunction, displacement of indwelling tubes and lines, and/or complications associated with physiological deterioration.2,6 For instance, equipment malfunction may involve losing battery power on beds mid-transport, causing a loss of functionality and an abrupt halt in movement. Ventilator and intravenous medication administration tubing may not be long enough to maneuver into and out of elevators easily, or may become snagged, which can lead to disconnection or inadvertent removal. Problems involving oxygen delivery have been noted, such as unintended discontinuation of pulse oximetry monitoring and empty or improperly functioning oxygen tanks or inaccurate liter flow, which can compromise patient safety.5-6 Finally, physiologic deterioration in transport can include events such as respiratory or cardiac arrest, syncope, or life-threatening cardiac arrhythmias, as described in another WebM&M case.

Systematic Approaches to Improving Patient Safety with Intrahospital Transport

Regardless of the type of transport (i.e., scheduled, urgent, or emergent) or level of automation available in a healthcare institution, several best practices and strategies should be implemented to promote patient safety when transporting patients within a healthcare facility.

Dedicated Transport Team and Standardized Transport Workflows

Institutions can utilize a centralized, dedicated transport team, whose primary role is to focus on safe, timely patient transport.4 In this role, transporters focus on safe, standardized workflows related to the physical handoff and information handoff, strengthening connections between the care team and the patient.6 Specific examples include (a) bringing the proper equipment to the bedside and verifying its condition; (b) discussing the patient’s transfer, code status, and other pertinent information with the ordering/sending clinician; and (c) engaging the patient by introducing themselves using the patient's first and last name and verbally confirming the destination with the (conscious) patient. Conversing with the patient using appropriate identifiers acts as a second check to ensure that the right patient is being transferred. Upon arrival at the destination, the transporter should again confirm the patient’s identity and correct destination with the receiving clinician.

In addition to these workflows, recommendations to optimize intrahospital transport include thorough equipment checks and reassessments, written protocols, and implementation of checklists to ensure adherence to each component.2,4-7 In one example, Nakayama and a multidisciplinary team developed a nurse-to-nurse in person checklist for intrahospital transfers involving inpatients undergoing surgery. The checklist included patient demographic, procedural, medication and overall status data and required staff to sign the checklist following review. Following implementation of the checklist, incidence of intrahospital transport errors decreased significantly.7 Utilizing a standardized process or checklist can increase patient safety of patient transport and prevent transport-related errors without adding costly technology.

Patient Identification in the Operating Room

The OR utilizes its own specialized workflows to ensure correct patient identification prior to surgery, which is how the transport error was identified in Case #1. In the OR, whether the patient is transported to a pre-op area or directly to the OR (i.e., intensive care unit (ICU) direct transfer of emergent cases), the critical patient identification process is initiated by the circulating nurse. This Universal Protocol involves confirmation of the correct patient, correct procedure, and correct surgical/procedural site prior to initiating an invasive procedure.8 During the pre-op interview, the patient’s identity is confirmed with two patient identification (ID) bands (including patient name, medical record number, and date of birth) and if possible, the participation of the patient. If an emergency case arrives directly to the OR, the handoff between the sending and receiving nurses is critical to ensure appropriate ID bands are in place. In addition, a pre-procedure huddle is conducted either in the pre-op area or the OR with the anesthesia provider, surgeon, and nurse, where, once again, the patient’s identity is confirmed. The final safety check is performed during the pre-incision surgical time out which requires all staff to stop activity and dedicate their full attention to this critical check. If there are any discrepancies during any of these checks, the nurse must stop and resolve them before proceeding. Lastly, when transferring a patient out of the OR to the post-anesthesia care unit (PACU) or directly to an inpatient unit, another nurse-to-nurse handoff is completed. These safety checks help ensure that the correct care is provided to the correct patient.

Technology to Enhance Safety in Patient Transport

While technology should never take the place of professional exchanges and handoffs between the ordering clinician, transporter, and receiving clinician, electronic health record (EHR) and software systems can provide a central dashboard that can be viewed in real-time by healthcare staff to track patient flow. These software applications display patient location, mode of travel, transporter contact information, and other functions to promote efficiency and safety in the patient transport process by allowing services to be booked online and conveying information immediately.4,9 Along with dedicated transport staff, technology can facilitate safe patient transport by (a) ordering patient transportation linked to a specific individual via the EHR, (b) implementing use of a handheld rover device to scan the patient's ID band for verification prior to transport; and (c) providing a ‘hard stop’ to alert the transporter if the incorrect patient is scanned for transport. In addition, handheld scanning devices increasingly have the option to display a picture of the patient and other identifying information, including the patient’s name, medical record number, date of birth, height, weight, isolation level, and code status to help correctly identify the patient and prevent in-transport errors.


In both cases, the transport-related errors could have been prevented if best practices discussed in this commentary had been utilized. The initial transport error in Case #1 was detected in a pre-procedural huddle within the OR and in Case #2 the inappropriate transport was identified after an unnecessary x-ray was performed. Employing a standardized patient identification process that includes verifying patient identification bands by confirming name and birthday with the procedural order and destination prior to initiating the intrahospital transport is foundational to any transport process. In addition, utilization of a checklist or an electronic system can help to further standardize and maintain best practices for intrahospital patient transport.

Take Home Points

  • Medical errors can occur when patients are transported either within or between healthcare facilities. These errors include transporting the wrong patient, transporting to the wrong location, communication or handoff problems leading to missed or delayed orders or treatments, and equipment malfunction.
  • The consequences of these errors include patient harm, delays in care, increased healthcare costs, and “wrong procedure” sentinel events.
  • Creating standardized workflows, maintaining a dedicated transport team, and implementing technologic innovations can enhance the safety of patient transport and prevent transport-related errors.


Assistant Nurse Manager, Professional Development
Department of Emergency Medicine
UC Davis Health

James Rice
Manager, Patient Transport Services
UC Davis Health

Julie Chou, BSN, CNOR
Main Operating Room
UC Davis Health

Acknowledgement: The authors would like to thank Sarina Fazio and the Center for Nursing Science at UC Davis Health for assistance with commentary preparation.


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  8. American College of Surgeons (ACS) Committee on Perioperative Care. Revised statement on safe surgery checklists, and ensuring correct patient, correct site, and correct procedure surgery. Bull Am Coll Surg. 2016;101(10):52. [Free full text]
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This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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