Background

When I was asked to revise the Trust’s patient transfer policy, I was aware that this was more than just a routine administrative task. With over 12 years’ experience in critical care outreach and a current role in patient safety, I had seen first-hand how policy can often fail to reflect the realities of frontline practice. I was given three months to complete the update, with a clear objective: to ensure the safe transfer of patients within hospital departments, across different hospital sites and to external healthcare providers. Transfers to home were not within scope.

What struck me early on was how frequently policies are written by individuals who, though senior and highly experienced, may no longer be closely connected to the clinical day-to-day. This can result in a disconnect between 'work as imagined' and 'work as done'.[1] To address this, I adopted a Safety-II perspective—focusing not just on what goes wrong, but on what goes right in everyday operations.[2]

My goal was to produce a practical, patient-centred policy that staff could confidently apply in real-world situations.

What I did

The existing policy was lengthy, complex and delivered in a dense narrative format. It included extensive lists of responsibilities for both transferring and receiving staff and it required staff to refer to a separate, standalone policy for medication transfers. As a practising nurse, I found the original version difficult to use—and I was not alone.

Recognising this, I started by reviewing the policy through the lens of my clinical experience. I considered the wide range of transfer types: from critically unwell patients in intensive care to stable individuals moving to a general ward; from straightforward intra-hospital moves to more complex inter-site transfers. The variables were numerous: time of day, staffing levels, patient acuity and even the involvement of non-clinical staff.

Understanding this complexity helped reinforce that a rigid, one-size-fits-all policy would not be fit for purpose. Instead, staff needed guidance that allowed for clinical judgement and flexibility—particularly in dynamic environments like the emergency department (ED), where many transfers occur.

To inform my work, I conducted observational visits in the ED. This was a deliberate decision, made to explore where and how transfers were most frequent. Unsurprisingly, I found that staff were rarely referring to the existing policy or checklists. Despite this, most transfers were completed safely, further demonstrating that frontline knowledge and adaptive capacity were strong. However, one recurrent concern emerged: uncertainty around who should escort patients during transfer, especially those with higher clinical risk. 

I then facilitated a focus group with frontline staff, who consistently reported that existing tools lacked decision-making support. The digital checklist in use addressed only basic administrative tasks, offering little guidance for clinical risk assessment.

In response, I worked with subject matter experts to develop a visual, easy-to-use risk stratification tool:

This matrix considered patient acuity (via NEWS2), clinical condition and any additional complexities. It was designed to support decision making on the appropriate level of clinical escort required for safe transfer.

While the tool is applicable to most adult acute settings, certain areas—such as maternity, paediatrics, and specialist theatres—require their own local adaptations. Therefore, the policy encourages staff in these areas to refer to their departmental standard operating procedures.

To enhance usability, I embedded the matrix into the policy as an appendix and integrated it into the Trust’s digital documentation system. This ensured easy access for staff during the transfer planning process and reduced the likelihood of bypassing key safety steps.

Reflections

Implementing a Safety-II approach in policy development was unfamiliar territory for me and, at times, it was daunting. The initial lack of precedent or internal guidance meant I had to trust the process and remain grounded in clinical realities. That said, support from my colleagues, particularly within the patient safety team, was instrumental in maintaining momentum.

Crucially, success depended on listening to frontline voices. Engaging staff through observation and feedback created a sense of shared ownership and helped overcome resistance. Rather than prescribing a rigid set of instructions, the final policy reflects the complexity of healthcare while offering clarity where it is most needed.

In developing this policy, I have gained a deeper appreciation for the value of designing with—not just for—those who do the work. Safety-II has helped shift our organisational lens from reactive to proactive, making room for learning from everyday success, not just failure.

References

1. Hollnagel E. Safety-I and Safety-II: The Past and Future of Safety Management. Farnham: Ashgate; 2014.
2. Hollnagel E, Wears RL, Braithwaite J. From Safety-I to Safety-II: A White Paper. [Online] The Resilient Health Care Net, 2015.

Related reading on the hub:

• Obstetricians approach to proactive safety management
• Turning Safety-II thinking into action (17 January 2022)
• Patient Safety: Emerging Applications of Safety Science
• Putting the writing on the wall: Explaining work as imagined vs work as done

1. Stable vital signs
2. Intact aeration
3. Medications reviewed
4. Prepared psychology
5. Lingering catheters
6. Extreme laboratory findings, and
7. Return plans.

The authors state: "The first 3 steps are prerequisites in a medical ward and denote the importance of stable vitals signs, intact aeration, and a diligent medication check. The next 3 steps are priorities in the ICU and involve determining patient expectations, managing catheters or other devices, and reviewing laboratory results. The final step concerns contingency plans for unforeseen deteriorations and goals of care."

By using the standard professionals will have access to all relevant information in a timely manner results in safer and more consistent care for people using health and care services. The information will include data about medication, previous history, allergies and current symptoms, as well as a patient’s concerns and expectations.

This standard has now been updated to version 1.1. Detailed release notes are available outlining the changes. These can be found in the supporting documents link above. The standard has been updated in-line with new PRSB digital medications information assurance.

The PRSB has worked in partnership with the Health Informatics Unit at the Royal College of Physicians to produce these standards.

Yorkshire & Humber AHSN are supporting Sustainability and Transformation Partnerships and Hospital Trusts to implement the Connect with Pharmacy. This will ensure that detailed changes to a patient’s medication are properly shared between hospitals and community settings. This video describes the project in more detail.

The tool also tracks data over time and uses a technique called statistical process control (SPC) to:

• identify when interventions result in an improvement
• highlight when activities are not resulting in change, indicating that a change of approach is required

SPC is one of the best ways to look at data as it identifies change that is statistically significant rather than due to chance. 

The authors conclude that significant communication gaps exist between primary and secondary care and that further research is needed to understand how to address them.