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Table 2 Top ten most commonly reported intra-hospital transport (IHT)-related incidents

From: A comprehensive method to develop a checklist to increase safety of intra-hospital transport of critically ill patients

Top 10 routinely registered IHT related incidentsa Pre-transport During transport Post-transport Total
Equipment malfunction 9 24 1 34
Preparation before transport 30 0 0 30
Lack of communication with radiology department 1 5 0 6
Dislocation of intravenous lines and tubing 0 12 1 13
Oxygen tank empty 4 4 0 8
Increase need vasopressor or inotropics 0 3 0 3
Equipment not available at radiology department 0 5 0 5
Lack of documentation in medical chart 0 0 2 2
Failure reconnect humidifier on ventilator 0 0 11 11
Hypoglycemia 0 0 1 1
Top ten prospectively collected IHT-related incidentsb     
Equipment malfunction 7 24 2 33
Preparation before transport 6 5 0 11
Lack of communication with radiology department 5 5 0 10
Dislocation intravenous line 0 7 2 9
Oxygen tank empty 4 2 0 6
Increase need vasopressor or inotropics 5 15 6 26
Low blood pressure§ 21 44 18 83
Hypoxia§/increased oxygen demand 5 18 12 35
Increased need sedatives or opiods due to agitation 2 17 2 21
Hypertension§ 2 9 3 14
  1. aAnalysis of transport-related incidents that were identified from routinely collected incidents in an elecronic incident reporting system in Leiden University Medical Center. bFor 12 months all incidents occurring during intra-hospital transport were prospectively collected. §No definitions were used to define hypotension, hypertension and hypoxia. Physicians and nurses were able to judge whether it deviated.