A prospective review of adverse events during interhospital transfers of neonates by a dedicated neonatal transfer service.
OBJECTIVE
To categorize and quantify adverse events occurring during emergency interhospital transfers performed by a specialized neonatal retrieval team and to assign levels of associated risk.


METHODS
Prospective review of adverse events during emergency interhospital transfers of neonates by the London Neonatal Transfer Service over a 6-month period. The events were categorized based on an adapted retrieval team model from the Paediatric & Neonatal Safe Transfer and Retrieval Course (PANSTAR). Risk levels were measured using a modified risk assessment score.


METHODS
Emergency interhospital transfers by a specialized neonatal retrieval team.


METHODS
Patients were 346 emergency neonatal transfers over 6 months.


METHODS
None.


RESULTS
We found that 125 transfers (36.1%) had at least one adverse event. There were 205 adverse events in total; 139 events (67%) were perceived as being due to avoidable human errors. Almost a third of events (30%) occurred even before the retrieval team arrived at the referring hospital and made contact with the patient. The largest group of events occurred due to problems in preparation (n = 69) and communication (n = 49). Most events (n = 143) had insignificant impacts on patients, but six events could have potentially caused major harm.


CONCLUSIONS
Adverse events commonly occur during neonatal transfers, even if performed by a dedicated transfer service. Early identification of potentially harmful episodes is important. Human error is likely to be a factor in the majority of adverse events; hence, opportunities should be taken to reduce the number of these through education, training, and risk management.
Lim
Michael Teik Chung
MT
Royal London Hospital, London, United Kingdom. miketclim@yahoo.co.uk
Ratnavel
Nandiran
N
D004632:Emergency Medical Services; D006801:Humans; D007231:Infant, Newborn; D019300:Medical Errors / Q000706:statistics & numerical data*; D010360:Patient Transfer / Q000592:standards; D011446:Prospective Studies; D018570:Risk Assessment