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Table 5 Examples of recorded adverse events

From: Quality of interhospital transport of critically ill patients: a prospective audit

Transfer characteristics Adverse event Severity (grade 1–3)a
Pulmonary embolus PaO2 on departure 4.2 kPa; not intubated; PaO2 on arrival 4.7 kPa 3
Oesophageal bleeding Only one peripheral intravenous line; no accompanying physician; active bleeding; PaO2 on arrival 6.7 kPa 3
Sepsis, rhabdomyolysis RI; shock on arrival 2
Imminent RI; Wegener's granulomatosis No blood pressure measured on the road (160 km); PaO2 on arrival 6.7 kPa, SaO2 86% 1
Pulmonary embolus No accompanying physician; RI on arrival 2
ARDS, MOF SaO2 93% at departure, 69% on arrival 3
Streptococcal pneumonia/sepsis; imminent RI Not intubated (despite advice); norepinephrine via peripheral intravenous line 3
Sleep apnoea syndrome; RI PaO2 on departure 6.9 kPa; during transport SaO2↓ 74% and cardiac ischaemia; no physician 3
Haemorragic shock; mechanical ventilation No accompanying physician; active bleeding (3 units packed cells on the road); oxygenation problems 3
Infectious endocarditis; mechanical ventilation No physician; haemodynamically unstable on the road 1
Septic shock; imminent RI Not intubated (despite advice); RI on arrival 3
Septic shock; MOF Norepinephrine via peripheral intravenous line 2
Suicide attempt (benzodiazepine) Deep coma; not intubated; apnoea en route; cyanotic on arrival 3
Postsurgical; mechanical ventilation Oxygen supply breakdown before arrival 3
COPD, pneumonia Shortage of oxygen before arrival 3
Haemodyalisis postsurgical No blood pressure measured on the road 1
Active bleeding digestive tract Only one peripheral intravenous line 1
ARDS; mechanical ventilation Ambulance breakdown; 40 min delay 1
  1. aGrades of severity: grade 1 = deviation from guidelines/protocol; grade 2 = of vital importance – immediate action needed on arrival; and grade 3 = of vital importance – immediate action needed on arrival – event probably avoidable. ARDS, acute respiratory distress syndrome; MOF, multiple organ failure; PaO2, arterial oxygen tension; RI, respiratory insufficiency (imminent need for mechanical ventilation); SaO2, arterial oxygen saturation.