• Lina M Bergman, Monica E Pettersson, Wendy P Chaboyer, Eric D Carlström, and Mona L Ringdal.
• 1Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. 2The Vascular Department, Sahlgrenska University Hospital/Sahlgrenska, Gothenburg, Sweden. 3Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia. 4University College of Southeast Norway, Notodden, Norway. 5Department of Anesthesiology and Intensive Care, Kungälvs Hospital, Kungälv, Sweden.
• Crit. Care Med. 2017 Oct 1; 45 (10): e1043-e1049.

ObjectiveTo identify, classify, and describe safety hazards during the process of intrahospital transport of critically ill patients.DesignA prospective observational study. Data from participant observations of the intrahospital transport process were collected over a period of 3 months.SettingThe study was undertaken at two ICUs in one university hospital.PatientsCritically ill patients transported within the hospital by critical care nurses, unlicensed nurses, and physicians.InterventionsNone.Measurements And Main ResultsContent 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.ConclusionsFindings 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.

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