Traffic lights: putting a stop to unsafe patient transfers.

Poor handover between doctors is a recognised cause of error in hospitals.[1] Watford General Hospital is a busy acute trust in southern England, where high admission rates necessitate timely patient transfers from the acute admissions unit (AAU) to the medical wards. We found that doctors were infrequently informed of patient transfers, and they rarely handed over patient care when a patient was moved. Our aim was to minimise preventable harm to patients by prompting handover of clinically unstable patients, and patients with outstanding investigations or referrals, at the time of transfer. We introduced a traffic light tool to categorise patients on the medical take as red, amber, or green according to their clinical status at time of admission to AAU. The traffic light colour, which was assigned both on paper and electronically, was designed to prompt a verbal handover between doctors at the time of patient transfer from AAU.