Incidence of patient safety events and process-related human failures during intra-hospital transportation of patients: retrospective exploration from the institutional incident reporting system

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.

Reporting and responding to patient safety incidents based on data from hospitals’ reporting systems: A systematic review

“…Sixteen (n = 16) papers were included in the final analysis. [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] We conducted the study selections with three researchers independently examining each paper phase by phase. Discussions were held to compare the selections, and in the case of disagreement, the decision about inclusion or exclusion was carried out through consensus.…”

“…Pitkä nen et al 2016 [25] Electronic/ Anonymous [26] Electronic/ Anonymous [27] Paper/ Non-anonymous [28] Electronic…”

“…Work organization-related incidents were incidents in which staff made mistakes with planning tasks or did not complete a task at all. The reasons described included failure to check, [13,18,23,27,28] a weak fit between the training and task [13,14,17,20,24,27] and lack of coordination when everyone thought that someone else had completed the task. [17] Staff failure to follow procedure guidelines or manage an escalated care situation and situations in which a patients' condition, behaviour or characteristics were beyond the control of staff [16,19] led to incidents like inadequate patient care or coordination, [20,21] falls, [14,[19][20][21] food aspiration [21] or tissue injuries [19] and death.…”

“…[16, 18-21, 23, 24] Staff who did not know the guidelines caused faulty monitoring, treatment or procedures. [16,18,20,28] Mistakes were made with patient identification or verification [14,17,18,20,26] and with obtaining a patient's informed consent. [14,23,24,26] For example, a blank informed consent form was signed by a patient, or no anaesthesia or surgical consent forms were signed at all, which resulted in the cancellation of a procedure, or a procedure was completed without documented patient consent.…”

“…Incidents were caused by equipment or equipment malfunctioning [14,17,18,26,27] or because the staff had made mistakes in their use. [16,21,27] In several studies, the cause of the incident was that the equipment or accessory was not available [13,16,24,28] or not properly placed (bedrails not being in place), [20] or the manufacturer's instructions were unclear. [24] In one study, environmental and facility malfunctions during intra-hospital transport resulted in incidents.…”