J Pediatr Res | Volume 5, Issue 1 | Research Article | Open Access

A Prospective Study of Patient Safety Incidents Occurring During Retrieval in a Regional Pediatric Transport Service

Michael G Purvis-Smith1,2, Sile T Smith1,2 and Christopher S James1,2*

1Department of Intensive Care, Royal Children’s Hospital, Australia 2Department of Pediatrics, Pediatric Infant and Perinatal Emergency Retrieval, Australia

*Correspondance to: Christopher S James 

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Introduction: The primary aim of this study was to quantify patient safety incident rates during retrieval in our state emergency pediatric transport service. Secondary aims were to describe the patient cohort and retrieval characteristics, including the interventions performed by the transport teams. Methods: This was a prospective, descriptive safety audit. Data relevant to patient safety incidents, retrieval and patient cohort characteristics, and team interventions were recorded and analyzed for 365 consecutive retrievals between February 11th and August 11th, 2018. Results: Half the patients were under two years old, respiratory illnesses dominated (233, 63.8%), and few were mechanically ventilated (44, 12.1%). There were 31.5 safety incidents per 100 retrievals, the most frequent being delayed urgent departures, equipment malfunction, and hypoxia (12.9, 4.4 and 4.1 per 100 retrievals respectively). Of those safety incidents, we considered 44.4% (16/36) preventable. There were 5.5 adverse events and 0.5 major harm incidents per 100 retrievals. Procedures by the team were infrequent, with only three central lines (0.8%) placed and four endotracheal intubations (1.1%) performed. Conclusion: Safety incidents during retrieval were common and often preventable, though rates of harm were substantially lower. These events occurred in a patient cohort that appeared to have a relatively low level of acuity when compared to other studies. Delayed departures were frequent and often related to team availability. Procedural interventions were uncommon which has implications for staff training. Overall, the study identified several important areas in which we may improve the safety of our service.


Patient transportation; Pediatric; Critical care; Patient safety; Data collection; Australia


Purvis-Smith MG, Smith ST, James CS. A Prospective Study of Patient Safety Incidents Occurring During Retrieval in a Regional Pediatric Transport Service. Ann Pediatr Res. 2021;5(1):1055..

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