Patient Safety Events during Critical Care Transport

Abstract

Objective: Patient safety events (PSEs) occurring during interfacility transport have not been studied comprehensively in critical care transport (CCT) teams in the United States. The purpose of this research was to investigate the type and frequency of PSEs during CCT between hospitals; to explore the impact of patient stability, vulnerability, complexity, predictability, and resiliency; and to examine if the nurse factors of licensure or experience and transport factors of duration or mode of transport influence the frequency of PSEs. The study was conducted at a large hospital-based quaternary health care system in the Midwestern United States.

Methods: This was a retrospective, descriptive correlational study using chart review. The study selected 50 sequential qualifying cases with PSEs and randomly selected control cases reviewed at a single site over a 5-month period.

Results: The rate of PSEs was 27.7 events per 1,000 patient contacts. Of 9 reported adverse event types, new or recurrent hypoxia had the greatest frequency. Hypoxia, when present at the time of initial CCT contact, was associated with the PSE occurrence (P = .046). Duration of transport was a significant predictor of PSEs (P = .025).

Conclusion: Pretransport hypoxia and duration of transport are independent predictors for intratransport PSEs, particularly intratransport hypoxia.