Analysis of adverse events associated with interhospital transfer of critically ill patients. Safety checklist

• Published in: Enfermeria intensiva Vol. 25; no. 2; p. 58
• Main Authors: Melgarejo Urendez, A, Bernat Adell, M D, Lorente García, P
• Format: Journal Article
• Language: Spanish
• Published: Spain 01-04-2014
• Subjects: Adult; Aged; Aged, 80 and over; Checklist; Critical Illness; Humans; Middle Aged; Patient Safety; Patient Transfer; Young Adult; Adverse events; Interhospital transfer; Traslado intrahospitalario; Paciente crítico; Critically ill patient; Eventos adversos
• ISSN: 1578-1291
• DOI: 10.1016/j.enfi.2014.03.004

Mobilization entails a risk for critically ill patients. It is therefore important to design and apply the tools to detect any safety lapses and to improve the quality of patient healthcare.
To identify which adverse events (AE) are related to interhospital transfer of assisted patients and how enabling a protocol may prevent potential risks.
Descriptive, observational study. We analyzed 110 transfers during morning shift in an Intensive Care Unit at a reference hospital between January and March 2011. Variables related to underlying security factors were collected.
The average transfer time was 37.16 minutes. 61.82% of the transfers were carried out on a scheduled basis. An 18.18% of AE were detected. In both cases, desaturation and hemodynamic instability made up to 2.7% of the cases. 5.5% of the cases were underlying factors related to monitoring during transfer, and those related to ventilation during transfer accounted for 2.7%. Not having all materials by the stretcher constituted 1.8%. We detected 31 AE for non-compliance with the protocol, that being a 27.15% of all transfers.
Before each hospital transfer, a risk-benefit assessment is recommended in order to avoid potential alterations in the patient's pathophysiologic condition. Both the protocol and the safety checklist are key to detect underlying factors and improve security during interhospital transfers.