Towards safer neonatal transfer: the importance of critical incident review

• Published in: Archives of disease in childhood Vol. 90; no. 7; pp. 729 - 732
• Main Authors: Moss, S J, Embleton, N D, Fenton, A C
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health 01.07.2005; BMJ; BMJ Publishing Group Ltd; BMJ Publishing Group LTD
• Subjects: Ambulances - standards; Biological and medical sciences; Births; Body Weight; Care and treatment; critical incidents; Critically ill children; England; Environment; Hospitals; Humans; Infant Care - methods; Infant Care - standards; Infant, Newborn; Intensive care; Intensive care units; inter-hospital transfer; Medical sciences; Miscellaneous; Neonates; Nursing; Original; Patients; Pregnancy; Public health. Hygiene; Public health. Hygiene-occupational medicine; Retrospective Studies; Risk Management; Statistical Analysis; Task Performance and Analysis; Transportation of Patients - methods; Transportation of Patients - standards; Transportation of Patients - utilization; Young Children; United Kingdom; Europe; England; Human; Pediatrics; Newborn; Organization; Medical transport; Critically ill; Quality; Neonatology; Critical incident; Hospital; Safety; Public health
• ISSN: 0003-9888; 1468-2044
• DOI: 10.1136/adc.2004.066639

Background: Critical incidents are common during the inter-hospital transfer of sick patients, and infants are an especially vulnerable group. Aims: To examine the effect of critical incident review on the number of adverse events during inter-hospital transfer of sick infants. Methods: Critical incidents over an eight year period are reported from a single neonatal transfer service before and after major service changes were made. The changes were instigated as part of ongoing critical incident reviews. Results: Changes made as a result of critical incident review significantly reduced the number of incidents contributed to by poor preparation, transport equipment or clinical problems, ambulance delays, and ambulance equipment failure. Conclusions: The continuous process of critical incident reporting and review can reduce the number of adverse events during the transfer of critically ill infants.