NU 730 Unit 3 handoff failure analysis example

A Twelve-Hour Antibiotic Gap After Emergency Department to ICU Transfer: A Handoff Failure Analysis

Student Name

Department of Nursing, Herzing University

NU 730: Systems-Based Practice

Instructor Name

February 4, 2026

A Twelve-Hour Antibiotic Gap After Emergency Department to ICU Transfer: A Handoff Failure Analysis

The Transfer

This analysis concerns a composite case. Mrs. D., 71, came to the emergency department at 16:40 with fever, confusion, and hypotension from a urinary source. She met criteria for septic shock. The emergency team drew blood cultures, gave 30 mL/kg of intravenous fluid, and gave the first dose of piperacillin-tazobactam at 18:10, which was ordered every eight hours. She was admitted to the intensive care unit at 18:55, but no bed was ready, and she boarded in the emergency department until 22:30, when she was transferred. The next dose of piperacillin-tazobactam was given at 06:05 the following morning, nearly 12 hours after the first. Her lactate was not rechecked until 07:00. She required vasopressors overnight but survived and was discharged on day nine. No permanent harm was identified, but a dose of her key antibiotic was effectively missed during the most critical hours of septic shock, when timely antimicrobial treatment matters (Seymour et al., 2017).

Timeline

18:10: first dose given in the emergency department, documented in the emergency department medication administration record, next dose due 02:10. 18:55: intensive care admission orders entered by the intensivist through the admission order set, which included piperacillin-tazobactam every eight hours with the start time defaulting to the next standard administration time on the unit, 06:00. 19:30: the emergency nurse gave a verbal report by phone to the intensive care charge nurse, covering vital signs, fluids, and "antibiotics given." 21:00: the emergency department nurse caring for Mrs. D. was reassigned to a new trauma patient; a float nurse assumed her care. 22:30: transfer to the intensive care unit; the receiving nurse reviewed the active intensive care orders, which showed the next dose at 06:00. 02:10: the dose actually due passed without action. 06:05: dose given as scheduled on the intensive care orders.

What Existed, What Moved, and What Arrived

Information that was recorded but never read: the 18:10 administration time and the 02:10 due time were in the emergency department's administration record. They did not move into the intensive care orders, because the admission order set created a new order with its own default schedule rather than continuing the emergency order. The receiving nurse had access to the emergency record, but nothing prompted her to look, and the intensive care orders appeared complete.

Information that was never recorded: the plan to repeat the lactate within six hours. The emergency physician intended it and mentioned it to the intensivist by phone, but no order was entered, so it existed only in two people's memories and in neither record.

Information that moved but lost its meaning: the phrase "antibiotics given" in the verbal report. It was accurate but told the receiver neither when nor what was due next. Handoffs that lack structure are a recurring contributor to sentinel events, and structured handoff programs with standardized elements have reduced errors (Starmer et al., 2014).

The two failures differ in kind, and the difference matters for repair. The antibiotic gap was a failure of transmission: correct information existed in the system and did not reach the person who needed it. The missing lactate was a failure of capture: the plan never entered any record, so no design of the handoff could have carried it. The first calls for changes in how orders are built and displayed; the second calls for a habit, supported by the handoff format, of turning every stated plan into an order or a written task before the conversation ends.

Conditions That Made the Failure Likely

Order set design: the intensive care admission order set defaulted antibiotic start times to standard unit times, a reasonable design for elective admissions and a hazardous one for patients arriving with doses already given. No rule compared new antibiotic orders with recent administrations. Boarding: Mrs. D. spent more than three hours as an intensive care admission physically in the emergency department, under emergency nursing but with intensive care orders, a condition in which neither team fully owns the medication schedule. Workload and reassignment: the nurse who gave the first dose was reassigned before transfer, so the person who knew the due time was not the person who handed off. Unstructured verbal report: the phone report followed no standard format, and the receiving charge nurse was not the nurse who would care for the patient. Each condition alone might have been harmless; together they aligned, much as the model of accidents as holes lining up across layers of defense describes (Reason, 2000).

Why Blaming the Receiving Nurse Would Be Wrong

The receiving nurse followed the active orders, which looked complete and correct. Faulting her for not searching the emergency record for a discrepancy she had no reason to suspect would identify the last person in the chain rather than the conditions that set the trap. Any nurse receiving that patient through that order set during a boarding period would have been likely to make the same decision.

Changes Aimed at the Conditions

First, order set: change the intensive care antibiotic orders so that, for patients with a dose given in the previous 12 hours, the start time must be chosen explicitly, with the last administration time displayed. Second, decision support: add a rule that alerts the pharmacist when a new antibiotic order's first dose is more than two hours later than the due time based on the last recorded administration. Third, structured handoff: adopt a standardized handoff format for emergency to intensive care transfers, including last dose times and due times for time-critical medications, and pending tasks such as repeat lactate. Fourth, boarding ownership: define that, while a patient boards, the intensive care nurse or a designated boarding nurse owns the medication schedule, with an explicit handoff at the moment of admission rather than at physical transfer.

Measures: proportion of transferred patients with antibiotic gaps longer than the ordered interval, audited monthly for six months; time from admission to first intensive care antibiotic dose for patients who received one in the emergency department.

References

Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768

Seymour, C. W., Gesten, F., Prescott, H. C., Friedrich, M. E., Iwashyna, T. J., Phillips, G. S., Lemeshow, S., Osborn, T., Terry, K. M., & Levy, M. M. (2017). Time to treatment and mortality during mandated emergency care for sepsis. New England Journal of Medicine, 376(23), 2235-2244. https://doi.org/10.1056/NEJMoa1703058

Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., Noble, E. L., Tse, L. L., Dalal, A. K., Keohane, C. A., Lipsitz, S. R., Rothschild, J. M., Wien, M. F., Yoon, C. S., Zigmont, K. R., Wilson, K. M., O'Toole, J. K., Solan, L. G., Aylor, M., ... Landrigan, C. P. (2014). Changes in medical errors after implementation of a handoff program. New England Journal of Medicine, 371(19), 1803-1812. https://doi.org/10.1056/NEJMsa1405556