Skip to main content

Incidents related to intrahospital transport of patients in the ICU


The objective of this study was to determine the incidence and type of incidents related to intrahospital transport (IHT) of critically ill patients in our ICU and to identify contributing factors of these incidents.


Since 2006 an electronic incident registration system was implemented on our tertiary university mixed adult ICU. Two investigators identified incidents related to IHT between 2006 and 2009. IHT incidents were categorized according to phase of occurrence: before, during or after IHT. The physical derangement of the patients could be cardiovascular, respiratory, or neurologic. By means of a structured incident analysis method, potential causal and contributory factors were determined.


In a 1-year period (2009) 568 transports were performed in 1,821 ICU patients. Thus about one-third of all ICU patients needed IHT. Of all incidents reported from 2006 to 2009, 2.1% was IHT related. IHT had an incident rate of 3.7%. Of all IHT incidents (n = 124), 35% occurred pre-transport, 50% during transport and 15% post-transport. Thirty-two patients (25.8%) had a physical derangement. The most involved organ system was the respiratory system (n = 20) followed by the cardiovascular system (n = 10) and neurological problems (n = 2). Indentified causes were technical (n = 39), organizational (n = 50) and human error (n = 86); more than one cause per case could be assigned. Technical causes occurred mostly during transport (n = 28) followed by pre-transport (n = 9) and after transport (n = 2). Contributing factors were mostly equipment related (n = 22). Human error was divided between during transport (n = 35) and pre-transport (n = 33) and fewer occurred after transport (n = 18). Contributing factors were coordination errors (n = 37) and external factors (n = 19). Organizational causes were mostly pre-transport (n = 26) and during transport (n = 20) and fewer after transport (n = 4). Almost all contributing factors were due to information transfer (n = 31). Overall, the most important contributing factors were coordination errors (n = 37), information transfer (n = 31), equipment failure (n = 22), and insufficient supervision (n = 22).


Incidents related to IHT have an incidence of 3.7%. Most incidents occurred pre-transport and during transport. The incidents are predominantly on the respiratory and cardiovascular systems. Human failure is an important cause of IHT. Contributing factors were coordination errors, equipment failure, information transfer and insufficient supervision. Given the contributing factors we think the number of incidents could be reduced by means of a transportation checklist.

Author information



Corresponding author

Correspondence to C Van Velzen.

Rights and permissions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Cite this article

Van Velzen, C., Brunsveld-Reinders, A. & Arbous, M. Incidents related to intrahospital transport of patients in the ICU. Crit Care 15, P535 (2011).

Download citation


  • Cardiovascular System
  • Contribute Factor
  • Respiratory System
  • Information Transfer
  • Human Error