Analysis of critical incidents during the interhospital transport of critically ill patients

Introduction

In this study we created a database to analyse the incidence and types of critical incidents that occurred during the interhospital transfer of critically ill patients. The transfer of critically ill patients presents important risks and the safety of patients has been shown to be facilitated by the development of standard equipment and specialist teams [1]. The West of Scotland Shock team is a designated regional transfer service based in Glasgow. We are involved in the interhospital transfer of patients and not primary retrieval. A recent study looking at critical incidents during the intrahospital transport of the critically ill highlighted the risks posed, and recommended the monitoring of incidents in order to aid the continuous improvement in patient safety [2]. No similar study has been carried out looking at the interhospital transport of the critically ill patient.

Methods

The study was a cross-sectional analysis of critical incidents occurring during interhospital transport that were reported to the West of Scotland Shock Team critical incident database set up in September 2005. The information obtained was categorised into: (a) where the incident took place, (b) type of incident, (c) written description of events, (d) outcome (potential or actual harm to the patient) and (e) designation of the staff member reporting the incident.

Results

A total of 199 transfers were performed over the 6-month period. Thirty-four critical incidents were reported. Twenty-four (70%) incidents took place before, seven (21%) during and three (9%) after transfer. No patients sustained actual harm, 29 (85%) were perceived by the reporter to have suffered potential harm and the most common cause of this were delays in the transfer. No potential or actual harm was perceived in five (15%) of the incidents. Fifty-three per cent of events were reported by senior house officer grade and 47% of incidents were reported by a specialist registrar. Only one incident was reported by a nurse on the team.

Conclusion

Interhospital transport of critically ill patients can pose important risks. In our study no actual patient harm occurred although most incidents had the potential to cause harm. The majority of incidents were caused by system-based factors. This database has allowed us to perform continuous service development and education of staff.

Table 1 Causes of all incidents (irrespective of patient outcome)