Lina M Bergman1, Monica E Pettersson, Wendy P Chaboyer, Eric D Carlström, Mona L Ringdal. 1. 1Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. 2The Vascular Department, Sahlgrenska University Hospital/Sahlgrenska, Gothenburg, Sweden. 3Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia. 4University College of Southeast Norway, Notodden, Norway. 5Department of Anesthesiology and Intensive Care, Kungälvs Hospital, Kungälv, Sweden.
Abstract
OBJECTIVE: To identify, classify, and describe safety hazards during the process of intrahospital transport of critically ill patients. DESIGN: A prospective observational study. Data from participant observations of the intrahospital transport process were collected over a period of 3 months. SETTING: The study was undertaken at two ICUs in one university hospital. PATIENTS: Critically ill patients transported within the hospital by critical care nurses, unlicensed nurses, and physicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Content analysis was performed using deductive and inductive approaches. We detected a total of 365 safety hazards (median, 7; interquartile range, 4-10) during 51 intrahospital transports of critically ill patients, 80% of whom were mechanically ventilated. The majority of detected safety hazards were assessed as increasing the risk of harm, compromising patient safety (n = 204). Using the System Engineering Initiative for Patient Safety, we identified safety hazards related to the work system, as follows: team (n = 61), tasks (n = 83), tools and technologies (n = 124), environment (n = 48), and organization (n = 49). Inductive analysis provided an in-depth description of those safety hazards, contributing factors, and process-related outcomes. CONCLUSIONS: Findings suggest that intrahospital transport is a hazardous process for critically ill patients. We have identified several factors that may contribute to transport-related adverse events, which will provide the opportunity for the redesign of systems to enhance patient safety.
OBJECTIVE: To identify, classify, and describe safety hazards during the process of intrahospital transport of critically illpatients. DESIGN: A prospective observational study. Data from participant observations of the intrahospital transport process were collected over a period of 3 months. SETTING: The study was undertaken at two ICUs in one university hospital. PATIENTS: Critically illpatients transported within the hospital by critical care nurses, unlicensed nurses, and physicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Content analysis was performed using deductive and inductive approaches. We detected a total of 365 safety hazards (median, 7; interquartile range, 4-10) during 51 intrahospital transports of critically illpatients, 80% of whom were mechanically ventilated. The majority of detected safety hazards were assessed as increasing the risk of harm, compromising patient safety (n = 204). Using the System Engineering Initiative for Patient Safety, we identified safety hazards related to the work system, as follows: team (n = 61), tasks (n = 83), tools and technologies (n = 124), environment (n = 48), and organization (n = 49). Inductive analysis provided an in-depth description of those safety hazards, contributing factors, and process-related outcomes. CONCLUSIONS: Findings suggest that intrahospital transport is a hazardous process for critically illpatients. We have identified several factors that may contribute to transport-related adverse events, which will provide the opportunity for the redesign of systems to enhance patient safety.
Authors: Julia Natterer; Frida Rizzati; Marie-Hélène Perez; David Longchamp; Vivianne Amiet; Quentin DeHalleux; Kim Dao; Thomas Ferry Journal: J Pediatr Intensive Care Date: 2020-07-30
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