Safety Hazards During Intrahospital Transport: A Prospective Observational Study

Area of Science:

• Critical Care Medicine
• Patient Safety
• Healthcare Systems Engineering

Background:

• Intrahospital transport of critically ill patients is a common but inherently risky procedure.
• Potential for adverse events and patient harm exists during intra-hospital transfers.

Purpose of the Study:

• To systematically identify, classify, and describe safety hazards encountered during the intrahospital transport of critically ill patients.
• To provide a foundation for improving safety protocols and system design for patient transport.

Main Methods:

• A prospective observational study design was employed.
• Data were collected through direct observation of 51 intrahospital transports of critically ill patients over three months.
• Content analysis, using both deductive and inductive approaches, was used to categorize safety hazards.

Main Results:

• A total of 365 safety hazards were identified, with a median of 7 per transport.
• The majority of hazards (n=204) were assessed as increasing the risk of harm to patients.
• Hazards were categorized using the System Engineering Initiative for Patient Safety framework, with 'tools and technologies' (n=124) and 'tasks' (n=83) being the most frequent categories.

Conclusions:

• Intrahospital transport is a high-risk process for critically ill patients, necessitating focused safety interventions.
• The study identified key contributing factors to transport-related adverse events, offering opportunities for system redesign.
• Enhancing patient safety during intrahospital transport requires a comprehensive approach addressing work system elements like teamwork, tasks, tools, environment, and organization.