Patient safety during transfers from critical care: developing and assessing a checklist

Area of Science:

• Critical Care Medicine
• Patient Safety
• Quality Improvement

Background:

• Critically ill patients frequently require transfer from the intensive care unit (ICU) to other departments, such as imaging.
• These transfers carry inherent risks, including patient deterioration and potential incidents due to inadequate preparation of medicines, equipment, and monitoring.
• Human factor errors during patient transfers can significantly compromise patient safety in the ICU setting.

Purpose of the Study:

• To develop and evaluate a patient transfer checklist for use in the intensive care unit (ICU).
• To reduce the risk of patient safety incidents associated with interdepartmental transfers from the ICU.
• To assess the impact of a checklist on human factor errors during patient transfers.

Main Methods:

• A quality improvement project was conducted at an acute hospital trust's ICU.
• A patient transfer checklist was developed based on guidance from the Intensive Care Society.
• The checklist's effectiveness was evaluated using retrospective incident reports, an audit of staff compliance, and a user survey.

Main Results:

• The use of a patient transfer checklist in the ICU is associated with a reduction in patient safety incidents during transfers.
• Staff compliance with the checklist was audited, providing data on its practical implementation.
• A user survey indicated the potential benefits and challenges of checklist utilization.

Conclusions:

• Implementing a patient transfer checklist in the ICU is a valuable strategy for improving patient safety during transfers.
• A shift in workplace culture may be necessary to fully enhance the benefits of the checklist, particularly regarding incident reporting.
• Checklists serve as a tool to mitigate risks associated with patient transfers, but broader cultural changes are also important.