LAUSR

OBJECTIVE To identify, classify, and describe safety hazards during the process of intrahospital transport of critically ill patients. DESIGN A prospective observational study. Data from participant observations of the intrahospital transport process were collected over a period of 3 months. SETTING The study was undertaken at two ICUs in one university hospital. PATIENTS Critically ill patients transported within the hospital by critical care nurses, unlicensed nurses, and physicians. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Content 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. CONCLUSIONS Findings 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.