Incidents relating to the intra-hospital transfer of critically ill patients - An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care

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. Between 1993 and 1999, 176 reports were submitted describing 191 incidents. Seventy-five reports (39%) identified equipment problems, relating prominently to battery/power supply, transport ventilator and monitor function, access to patient elevators and intubation equipment. Hundred sixteen reports (61%) identified patient/staff management issues including poor communication, inadequate monitoring, incorrect set-up of equipment, artificial airway malpositioning and incorrect positioning of patients. Serious adverse outcomes occurred in 55 reports (31%) including 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. Communication problems, inadequate protocols, in-servicing/training and equipment were prominent equipment-related incidents. Errors of problem recognition and judgement, failure to follow protocols, inadequate patient preparation, haste and inattention were common management-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 patients. The adequate provision of highly qualified staff, specially designed and well maintained equipment, as well as continuous monitoring are essential to avoid/mitigate these incidents. Professional societies and local units should adopt guidelines/protocols for intra-hospital transportation. Monitoring of incidents should aid in the continuous improvement in patient safety.