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It identifies multiple error sources, including unclear communication among VA travel staff and clinical teams, confusion about appropriate transport type (BLS vs ACLS), and risks created by complex handoffs occurring at all hours. It analyzes the current workflow and presents proposed action items emphasizing standardized transport eligibility criteria and improved, closed-loop handoffs to reduce wrong-transport and timing-related failures.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/improving-patient-safety-at-discharge-a-review-of-beneficiary-travel-at-hines-va/508571/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/improving-patient-safety-at-discharge-a-review-of-beneficiary-travel-at-hines-va/508571.png","ImageObject",300,407,{"name":92,"@type":93},"iuabcfuw","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-04","2026-10-05",true,{"@type":102,"interactionType":103,"userInteractionCount":44},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What is the main safety issue addressed in the discharge review?","Question",{"text":112,"@type":113},"The review highlights potential errors in the Beneficiary Travel system that can affect safe transport at discharge, including communication breakdowns and unclear criteria for transport type.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What causes confusion in the current Beneficiary Travel process?",{"text":117,"@type":113},"The process involves multiple teams and varying transportation modes, with handoffs occurring throughout the day. It also lacks clarity about the correct eligibility and transport type (such as BLS vs ACLS).",{"name":119,"@type":110,"acceptedAnswer":120},"What action items are proposed to reduce discharge-related transport errors?",{"text":121,"@type":113},"The document proposes timely, closed-loop communication between physicians and the VA travel team, clearer ACLS/BLS transport criteria, role standardization, and improved handoffs—especially for discharges later in the day.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},508571,1791334824,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":44,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":139,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":144,"read_time":145,"preview_page_count":4},3985747874027,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Improving Patient Safety at Discharge: A Review of  \nBeneficiary Travel at Hines VA  \nFaisal Husain, MD  \nEdward Hines VA Medical Center  \nLoyola University Medical Center  \n(1) Background & Problem Statement  \n(3) Current Process  \n(5) Proposed Action Items  \n•The Beneficiary Travel program at the VA provides transport to veterans to and from the VA.  \n•While the program generally works efficiently, there are multiple sources for potential error within the system.  \n•The process involves multiple teams, varying modes of transportation based on patient needs and acuity, and handoffs occurring at all hours of the day.  \n•Additionally, the process itself is at times, convoluted and improvements can be made in streamlining the process.  \n(2) Fishbone Diagram  \nProcess  \nPeople  \nMultiple sources of potential communication breakdown exist in the process  \n- The process involves VA travel, social workers, physicians, nurses that can lead to errors in communication  \nClarity Regarding BT Travel Process/Appropriate Type of Transport  \n- Current BT travel process:  \nResident writes BT note  \nincluding: Mode (medicar, ambulance, etc.) and BLS vs ACLS  \nBT note generates BT consult that VA Travel addresses. Resident sign note AND consult.  \nSW discusses with Travel that there is note/consult generated.  \nTravel approves, denies, or requests more information.  \nOnce discharge ready, nurse calls Travel for transport. Travel calls ambulance.  \nPatient successfully leaves hospital.  \n~~ ~~ Risk of lack of clear  \n~~ ~~ Risk of human error  \ndocumentation  \nRisk of complex Risk of lack of   \n- The Office of Inspector General monitored SMT  \ntransfer process communication  \nRisk of handoffsat shift change  \n  Risk of multiple transitions of care  \nRisk of Wrong Transport, Wrong Location  \n(Special Mode Transportation) and found that inappropriate mode of transport ordered 13% of time [2]  \nHandoffs Occur at Shift Change  \nRisk of lack of clarity  \n- Primary teams often are no  \nof BT process  \ntime patient leaves hospital  \nRisk of lack of clarity orror [3] transport types  \nlonger available by allowing for potential  \nHandoffs  \nMethods/Policy  \n- Daytime hospital discharges are significantly safer but may be harder to implement [4] .  \n1. Clarity Regarding BT Process/Types of Transport  \n- Timely, closed loop communication between physician and VA travel team  \n- Communication of ACLS vs. BLS transport criteria  \n- Clearly defined roles needed for those involved in BT process with standardization of process  \n2. Improvement of Handoffs/Adjustment of Resources  \n- Discharges later in day should have standardized handoffs with focus on critical discharge information, decreasing potential for error  \n- Day prior to discharge planning to become focus of afternoon touchback rounds between social workers and physician teams rather than facilitating same day late discharge (if deemed safer)  \n(6) References  \nRyynänen, Olli-Pekka, et al. “Is Advanced Life Support Better than Basic Life Support in Prehospital Care? A Systematic Review.” Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, BioMed Central, 23 Nov. 2010, [www.ncbi.nlm.nih.gov/pmc/articles/PMC3001418/](www.ncbi.nlm.nih.gov/pmc/articles/PMC3001418/) .  \n“The Beneficiary Travel Program, Special Mode of Transportation Eligibility and Payment Controls”, Office of Audits and Evaluations, Office of the Inspector General. VA-OIG 15- 00022-139, May 7, 2018  \nWaring, Justin.“Hospital Discharge and Patient Safety: Reviews of the Literature.” An Ethnographic Study of Knowledge Sharing Across the Boundaries between Care Processes, Services and Organisations: the Contributions to ‘Safe’Hospital Discharge., U.S. National Library of Medicine, Sep. 2014  \nStephanie K Mueller, MD, MPH, Julie Fiskio, Schnipper J, Interhospital Transfer: Transfer Processes and Patient Outcomes. J. Hosp. Med 2019; 8; 486-491.  \nGratton, Matthew C, et al. “Prospective determination of medical necessity for","cbCaimVUSsdoPnie","https://ap.wps.com/l/cbCaimVUSsdoPnie","pdf",7774756,15,"English","# Background & Problem Statement\n# Current Process\n# Fishbone Diagram\n# Proposed Action Items\n# References\n# Development of a Standardized Hypothermia Protocol For Post Cardiac Arrest Patients","[{\"question\":\"What is the main safety issue addressed in the discharge review?\",\"answer\":\"The review highlights potential errors in the Beneficiary Travel system that can affect safe transport at discharge, including communication breakdowns and unclear criteria for transport type.\"},{\"question\":\"What causes confusion in the current Beneficiary Travel process?\",\"answer\":\"The process involves multiple teams and varying transportation modes, with handoffs occurring throughout the day. It also lacks clarity about the correct eligibility and transport type (such as BLS vs ACLS).\"},{\"question\":\"What action items are proposed to reduce discharge-related transport errors?\",\"answer\":\"The document proposes timely, closed-loop communication between physicians and the VA travel team, clearer ACLS/BLS transport criteria, role standardization, and improved handoffs—especially for discharges later in the day.\"}]","Improving Patient Safety at Discharge - A Review of Beneficiary Travel at Hines VA | PDF",1791228407,38]