Towards safer neonatal transfer: the importance of critical incident review.

Abstract:

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.

journal_name

Arch Dis Child

authors

Moss SJ,Embleton ND,Fenton AC

doi

10.1136/adc.2004.066639

subject

Has Abstract

pub_date

2005-07-01 00:00:00

pages

729-32

issue

7

eissn

0003-9888

issn

1468-2044

pii

adc.2004.066639

journal_volume

90

pub_type

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