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

Incidence of patient safety events and process-related human failures during intra-hospital transportation of patients: retrospective exploration from the institutional incident reporting system.
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Yang SH, Jerng JS, Chen LC, Li YT, Huang HF, Wu CL, Chan JY, Huang SF, Liang HW, Sun JS,


Yang SH, Jerng JS, Chen LC, Li YT, Huang HF, Wu CL, Chan JY, Huang SF, Liang HW, Sun JS, (click to view)

Yang SH, Jerng JS, Chen LC, Li YT, Huang HF, Wu CL, Chan JY, Huang SF, Liang HW, Sun JS,

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BMJ open 2017 11 037(11) e017932 doi 10.1136/bmjopen-2017-017932
Abstract
BACKGROUND
Intra-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.

OBJECTIVE
To perform a retrospective analysis of IHT-related events, human failures and unsafe acts.

SETTING
A hospital-wide process for the IHT and database from the incident reporting system in a medical centre in Taiwan.

PARTICIPANTS
All eligible IHT-related patient safety events between January 2010 to December 2015 were included.

MAIN OUTCOME MEASURES
Incidence rate of IHT-related patient safety events, human failure modes, and types of unsafe acts.

RESULTS
There 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. CONCLUSIONS
This 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.

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