|
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
|
