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

Abstract

Critical incidents are common during the inter-hospital transfer of sick patients, and infants are an especially vulnerable group. To examine the effect of critical incident review on the number of adverse events during inter-hospital transfer of sick infants. 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. 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. The continuous process of critical incident reporting and review can reduce the number of adverse events during the transfer of critically ill infants.