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What’s New in the
Patient Safety World
April 2022
Safety Issues in
Interhospital Transports
We’ve done many
columns on problems associated with intrahospital transports (see list at the
end of today’s column), but only one specifically on interhospital transfers or
transports (our October 30, 2018 Patient Safety Tip of the Week “Interhospital
Transfers”). Of course, many of the
same problems seen during intrahospital transports may also occur during
interhospital tansfers but there are additional
considerations.
A recent Norwegian study of interhospital transports of critically ill patients (Eiding 2022) revealed a very high number of incidents. Despite this fact, these incidents are severely underreported in the hospital’s electronic incident reporting system. This suggests that learning is lost and errors with predominant probability are repeated. These results emphasize the existing challenges in regard to the quality and safety of interhospital transport of critically ill patients.
Personnel involved in interhospital transports of critically ill patients for 2 services filled out forms after each transport for 8 and 12 months, respectively. Service A reported incidents during 48% of their transports, with up to 7 unique incidents reported during a single transport. Service B reported incidents during 49% of their transports, with up to 4 unique incidents during a single transport. There was an average of 0.65 unique incidents per transport. These occurred “during loading” (30%), “during transport” (35%), and “during handover” (35%), with some of the incidents occurring in more than one
phase of the transport. Incidents were categorized as medical (15%), technical (25%), missing equipment (17%), and personal failures and communication difficulties (42%). But only 3 (1%) of the 294 unique incidents were actually reported in the hospital’s electronic incident reporting system.
A group of senior prehospital physician experts evaluated the materials, and were asked to consider which incidents should have been reported in the hospital’s electronic incident reporting system and suggest an intervention to avoid the incident in the future. The expert group advised that 28 (10%), 33 (11%), and 250 (85%) of the registered incidents should have been reported in the hospital’s electronic incident reporting system.
There was considerable variability among the three expert reviewers in terms of significance of both the severity and reportability of the incidents. Quite frankly, that wide variability among the three expert reviewers makes interpretation of the study difficult. But the main conclusion, that incidents are common during interhospital transports of critically ill patients and are significantly underreported, probably holds true. The authors stress that important lessons may be missed, and system errors likely have a high probability of being repeated. Thus, an opportunity to make the process safer may be missed. Service quality and transport safety also may be overrated.
We hope you will go
back to our October 30, 2018 Patient Safety Tip of the Week “Interhospital
Transfers” for an extensive
discussion of the types of incidents that occur during interhospital transports
and transfers. Other lessons are in our many columns on intrahospital
transports and those on medical air transports.
Some of our prior columns on intrahospital transports and the “Ticket to Ride” concept:
- April 8, 2008 “Oxygen as a Medication”
- November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
- August 11, 2009 “The Radiology Suite…Again!”
- March 13, 2012 “Medical Emergency Team Calls to Radiology”
- August 25, 2015 “Checklist for Intrahospital Transport”
- September 1, 2015 “Smarter Checklists”
- November 2016 “Oxygen
Tank Monitoring”
- February 2018 “Oxygen
Cylinders Back in the News”
- May 22, 2018 “Hazardous
Intrahospital Transport”
- October 30, 2018 “Interhospital
Transfers”
- March 31, 2020 “Intrahospital Transport
Issues in Children”
- June 23, 2020 “Telemetry Incidents”
- July 14, 2020 “A Thesis on
Intrahospital Transports”
- August 4, 2020 “Intravenous Issues”
- February 2021 “Risk from Intrahospital
Transfer: Healthcare-Associated Infection”
- May 25, 2021 “Yes, Radiologists Have
Handoffs, Too”
- July 2021 “Unique Way to Rapidly
Identify Oxygen Flow”
Our prior columns dealing with medical helicopter issues:
July 8, 2008 “Medical Helicopter Crashes”
October 2008 “More Medical Helicopter Crashes”
February 3, 2009 “NTSB Medical Helicopter Crash Reports: Missing the Big Picture”
September 1, 2009 “The Real Root Causes of Medical Helicopter Crashes”
November 2010 “FAA Safety Guidelines for Medical Helicopters
Short-Sighted”
March 2012 “Helicopter Transport and Stroke”
April 16, 2013 “Distracted While Texting”
August 20, 2013 “Lessons from Canadian Analysis of Medical Air
Transport Cases”
December 29, 2015 “More
Medical Helicopter Hazards”
October 30, 2018 “Interhospital
Transfers”
References:
Eiding H, Røise O, Kongsgaard UE. Potentially Severe Incidents During Interhospital Transport of Critically Ill Patients, Frequently Occurring But Rarely Reported: A Prospective Study. Journal of Patient Safety 2022; 18(1): e315-e319
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