Incidents relating to the intra-hospital transfer of critically ill patients

Abstract

Objective: Transportation of critically ill patients within the hospital poses important risks. We sought to identify causes, outcomes and contributing factors associated with intra-hospital transport. Design: Cross-sectional case review. Setting: Incident reports submitted to the Australian Incident Monitoring Study in Intensive Care (AIMS-ICU). Measurement and main results: Be-tween 1993 and 1999, 176 reports were submitted describing 191 inci-dents. Seventy-five reports (39%) identified equipment problems, relat-ing prominently to battery/power supply, transport ventilator and mon-itor function, access to patient eleva-tors and intubation equipment. Hun-dred sixteen reports (61%) identified patient/staff management issues in-cluding poor communication, inade-quate monitoring, incorrect set-up of equipment, artificial airway malposi-tioning and incorrect positioning of patients. Serious adverse outcomes occurred in 55 reports (31%) includ-ing major physiological derangement (15%), patient/relative dissatisfaction (7%), prolonged hospital stay (4%), physical/psychological injury (3%) and death (2%). Of 900 contributing factors identified, 46% were system-based and 54% human-based. Com-munication problems, inadequate protocols, in-servicing/training and equipment were prominent equip-ment-related incidents. Errors of problem recognition and judgement, failure to follow protocols, inade-quate patient preparation, haste and inattention were common manage-ment-related incidents. Rechecking the patient and equipment, skilled assistance and prior experience were important factors limiting harm. Conclusions: Intra-hospital transport poses an important risk to ICU pa-tients. The adequate provision of highly qualified staff, specially de-signed and well maintained equip-ment, as well as continuous moni-toring are essential to avoid/mitigate these incidents. Professional societies and local units should adopt guide-lines/protocols for intra-hospital transportation. Monitoring of inci-dents should aid in the continuous improvement in patient safety.