There is added risk each time a patient is transferred between healthcare sites or organizations (Anthony et al. 2005; Freitag and Carroll 2011; Manser et al. 2010; Sorrentino 2016). At our multi-site organization, such transfers are common, most often occurring for the purpose of access to diagnostic services. We sought to better understand the origins of those risks, prioritize them and establish relevant changes to processes and procedures to reduce such risks through the use of a failure mode and effects analysis (FMEA). We engaged with 50 stakeholders during the FMEA and used our organizational process improvement structure, Grassroots Transformation, to effectively communicate and monitor movement toward our goal of reduced risk associated with interfacility transfers.

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