Potentially Severe Incidents During Interhospital Transport of Critically Ill Patients, Frequently Occurring But Rarely Reported: A Prospective Study.
Journal
Journal of patient safety
ISSN: 1549-8425
Titre abrégé: J Patient Saf
Pays: United States
ID NLM: 101233393
Informations de publication
Date de publication:
01 01 2022
01 01 2022
Historique:
pubmed:
11
9
2020
medline:
24
2
2022
entrez:
10
9
2020
Statut:
ppublish
Résumé
The out-of-hospital environment can pose significant challenges to the quality and safety of interhospital transport of critically ill patients. Because we lack knowledge of the occurrence of incidents, their potential consequences, and whether they are actually reported, this study was initiated. Two different services in Norway were asked to self-report incidents after every interhospital transport of critically ill patients. Sampling lasted for 12 and 8 months, respectively. An expert group evaluated each incident for severity and demand for reporting into the hospital's electronic incident reporting system. One year later, the hospital's reporting system was scrutinized to determine the number of incidents actually reported. A total of 455 transports of critically ill patients were performed, resulting in 294 unique incidents reported: medical (15%), technical (25%), missing equipment (17%), and personal failures and communication difficulties (42%). Only 3 (1%) of the 294 unique incidents were actually reported in the hospital's electronic incident reporting system. The experts were inconsistent in which incidents should have been reported and to what degree checklists, standard operating procedures, simulation, and training could have prevented the incidents. This study of interhospital transports of critically ill patients reveals 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.
Identifiants
pubmed: 32910036
pii: 01209203-202201000-00051
doi: 10.1097/PTS.0000000000000769
pmc: PMC8719502
doi:
Types de publication
Journal Article
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
e315-e319Informations de copyright
Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc.
Déclaration de conflit d'intérêts
H.E. received funding from The Norwegian Air Ambulance Foundation. For the remaining authors, no conflicts of interest were declared.
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