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Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit


Objectives: To determine the incidence and nature of adverse events and delay to patient transfer from emergency department to intensive care unit (ICU) in a metropolitan tertiary hospital.

Method: A 6-month prospective observational study in conjunction with a retrospective chart audit on all emergency department patients admitted to ICU, including those admitted via theatre or after a computed tomography scan.

Results: Equipment problems was the most common adverse event occurring in 9% of patient transfers (n = 290). Hypothermia events occurred in 7% of transfers, cardiovascular events in 6% of patient transfers, delays to transfer >20 min occurred in 38% of the prospectively audited cases, with 14% waiting >1 h. One patient was found to have an incorrect patient identification band during a preoperative check.

Conclusions: This study generally reported lower rates of adverse events than noted in previous studies involving critically ill transfers. The most significant finding was the application of an incorrect patient identification band and has prompted a review of practice. The establishment of benchmark indicators for adverse events and delays in transfer will be useful for future audits.

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