Observational studyBMJ open2017
Incidence of patient safety events and process-related human failures during intra-hospital transportation of patients: retrospective exploration from the institutional incident reporting system.
Observational study in BMJ open, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 12 papers.
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
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Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
12 citing papers in PubMed.
- [Prospective study on application of mind mapping combined with scenario simulation training on the ability training of junior nurses in hospital transfer of patients with critical burns and trauma].Zhonghua shao shang yu chuang mian xiu fu za zhi · 2023Trial
- Mass intrahospital transport of the neonatal intensive care unit: a systems-based approach to safety, efficiency, and family-centered care.Journal of perinatology : official journal of the California Perinatal Association · 2026Article
- Psychometric properties of the Persian version of the intra-hospital transport safety scale in intensive care.SAGE open medicine · 2026Article
- Article
- MRI and the Critical Care Patient: Clinical, Operational, and Financial Challenges.Critical care research and practice · 2023Review
- Methodology for designing intrahospital transportation of patients with suspected infectious disease that limits infection spread risk in China.Frontiers in public health · 2022Article
- Effects of using a cognitive aid on content and feasibility of debriefings of simulated emergencies.GMS journal for medical education · 2021Article
- The Effects of ICU Crisis Reorganization on Outcomes in Patients Not Infected With Coronavirus Disease 2019 During the Initial Surge of the Coronavirus Disease 2019 Pandemic.Critical care explorations · 2021Article
- Development and initial psychometric testing of the Intrahospital Transport Safety Scale in intensive care.BMJ open · 2020Article
- Improving patient safety during intrahospital transportation of mechanically ventilated patients with critical illness.BMJ open quality · 2020Article
- A Quality Initiative Reducing Adverse Outcomes in Pediatric Patients with DKA During Intrafacility Transit.Pediatric quality & safetyArticle
- Implementation of an Intrahospital Transport Checklist for Emergency Department Admissions to Intensive Care.Pediatric quality & safetyArticle
Corrections and comments
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Authors and funding
10 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundIntra-hospital transportation (IHT) might compromise patient safety because of different care settings and higher demand on the human operation. Reports regarding the incidence of IHT-related patient safety events and human failures remain limited.
objectiveTo perform a retrospective analysis of IHT-related events, human failures and unsafe acts.
settingA hospital-wide process for the IHT and database from the incident reporting system in a medical centre in Taiwan.
participantsAll eligible IHT-related patient safety events between January 2010 to December 2015 were included.
main outcome measuresIncidence rate of IHT-related patient safety events, human failure modes, and types of unsafe acts.
resultsThere were 206 patient safety events in 2 009 013 IHT sessions (102.5 per 1 000 000 sessions). Most events (n=148, 71.8%) did not involve patient harm, and process events (n=146, 70.9%) were most common. Events at the location of arrival (n=101, 49.0%) were most frequent; this location accounted for 61.0% and 44.2% of events with patient harm and those without harm, respectively (p<0.001). Of the events with human failures (n=186), the most common related process step was the preparation of the transportation team (n=91, 48.9%). Contributing unsafe acts included perceptual errors (n=14, 7.5%), decision errors (n=56, 30.1%), skill-based errors (n=48, 25.8%), and non-compliance (n=68, 36.6%). Multivariate analysis showed that human failure found in the arrival and hand-off sub-process (OR 4.84, p<0.001) was associated with increased patient harm, whereas the presence of omission (OR 0.12, p<0.001) was associated with less patient harm.
conclusionsThis study shows a need to reduce human failures to prevent patient harm during intra-hospital transportation. We suggest that the transportation team pay specific attention to the sub-process at the location of arrival and prevent errors other than omissions. Long-term monitoring of IHT-related events is also warranted.
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