Our ED recently had a patient with a bad outcome after mis-triage. One of the things administration wants us to do to prevent such an event from happening again is to develop a written triage hand-off tool. I have never worked in an ED with any sort of formal triage hand-off. The off going triage nurse always briefs the on coming triage nurse about patients waiting--like who needs to come back first, if any patients are already in X-ray, etc. Does anyone out there formally document triage hand-off at shift change? If so, how do you do it? I think our administration is being unrealistic!