title: Towards safer neonatal transfer: the importance of critical incident review.
abstract: BACKGROUND
  Critical incidents are common during the inter-hospital transfer of sick patients, and infants are an especially vulnerable group.
  
  
  OBJECTIVE
  To examine the effect of critical incident review on the number of adverse events during inter-hospital transfer of sick infants.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  The continuous process of critical incident reporting and review can reduce the number of adverse events during the transfer of critically ill infants.
authors.affiliation: Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK. samanthajmoss@doctors.org.uk
authors.forename: S J
authors.initials: SJ
authors.lastname: Moss
authors.forename: N D
authors.initials: ND
authors.lastname: Embleton
authors.forename: A C
authors.initials: AC
authors.lastname: Fenton
mesh_terms: D000552:Ambulances / Q000592:standards; D004739:England; D006801:Humans; D007224:Infant Care / Q000379:methods / Q000592:standards*; D007231:Infant, Newborn; D012189:Retrospective Studies; D012308:Risk Management; D013647:Task Performance and Analysis; D014187:Transportation of Patients / Q000379:methods / Q000592:standards* / Q000706:statistics & numerical data