Hospitals in pursuit of excellence

Passport to Quality Care

Transplant recipients are fragile patients, at high risk for infections and fluid and electrolyte changes and requiring complex follow-up care. In 2009, the multivisceral transplant team at Cincinnati Children's Hospital Medical Center created a standard discharge process to (1) prevent errors and unplanned preventable occurrences, or UPOs?events that do not reach the patient but may cause communication or care delivery issues?and (2) improve communication and care delivery between caregivers and the medical team. The team's goal was zero preventable errors in 100 percent of patients and less than 1 UPO with every encounter. One communication intervention the team developed is a medical passport that "unifies assessment and communication at all care phases, including inpatient admissions, clinic visits, home health visits, and emergency room visits," says Denise Maseck, R.N. The medical passport includes active health and social problems, feeding regimen, medications, providers' contact numbers and more. Since October 2009, 100 percent of patients had zero errors and UPOs. Changes in patients' status are identified early with prompt communication that ensures safe and timely care. For more information, contact Maseck at denise.maseck@cchmc.org