A 3-month-old infant
was admitted with a respiratory syncytial virus (RSV) infection to
a pediatric medical unit. Although she was initially stable
(without oxygen requirements), her breathing soon became labored,
with an increased respiratory rate and subcostal retractions.
Providers determined that she would benefit from a higher level of
care and initiated the transfer process. This transfer happened to
coincide with a shift change for both the nursing staff and the
The off-going nurse assumed that the transfer
would take place immediately and signed out her patients to the
next nurse before the patient was physically moved. The outgoing
physician sent a text page to his incoming colleague with similar
sign-out. Approximately 45 minutes later, the unit clerk called the
infant's bedside nurse to report that the infant's parents believed
their child was in significant distress. The nurse was surprised
that the patient had not yet been transferred and, after an initial
evaluation, immediately called the rapid response team. The evening
physician was also contacted and was equally surprised by the
series of events. She had been told that the patient was being
transferred "non-emergently" to a unit for closer observation. The
patient was transferred to the intensive care unit (ICU), where she
made a full recovery, after a prolonged hospitalization.
performance improvement committee reviewed the case and determined
that improper delegation and lack of communication between staff
members contributed to the delay in treatment, and that improved
policies should be required for shift changes.
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