Incidents during out-of-hospital patient transportation

A. Flabouris, W. B. Runciman, B. Levings

Research output: Contribution to journalArticlepeer-review

41 Citations (Scopus)


Out-of-hospital patient transportation (retrieval) of critically ill patients occurs within highly complex environments. Adverse events are not uncommon. Incident monitoring provides a means to better understand such events. The aim of this study was to characterize incidents occurring during retrieval to provide a basis for developing corrective strategies. Four organizations contributed 125 reports, documenting 272 incidents; 91% of forms documented incidents as preventable. Incidents related to equipment (37%), patient care (26%), transport operations (11%), interpersonal communication (9%), planning or preparation (9%), retrieval staff (7%) and tasking (2%). Incidents occurred during patient transport to the receiving facility (26%), at patient origin (26%), during patient loading (20%), at the retrieval service base (18%) and receiving facility (9%). Contributing factors were system-based for 54% and human-based for 42%. Haste (7.5%), equipment malfunctioning (7.2%) or missing (5.5%), failure to check (5.8%) and pressure to proceed (5.2%) were the most frequent contributing factors. Harm was documented in 59% of incidents with one death. Minimizing factors were good crew skills/teamwork (42%), checking equipment (17%) and patient (8%), patient monitors (15%), good luck (14%) and good interpersonal communication (4%). Incident monitoring provides sufficient insight into retrieval incidents to be a useful quality improvement tool for retrieval services. Information gathered suggested improvements in retrieval equipment design and use of alternative power sources, the use of pro formae for equipment checking, patient assessment, preparation for transportation and information transfer. Lessons from incidents in other areas applicable to retrieval should be linked for analysis with retrieval incidents.

Original languageEnglish
Pages (from-to)228-236
Number of pages9
JournalAnaesthesia and Intensive Care
Issue number2
Publication statusPublished or Issued - Apr 2006
Externally publishedYes


  • Incident monitoring
  • Patient
  • Patient safety
  • Transportation

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Anesthesiology and Pain Medicine

Cite this