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.