Adverse events during air and ground neonatal transport: 13 years’ experience from a neonatal transport team in Northern Sweden

Abstract

Objective: To study the prevalence of adverse events (AEs) associated with neonatal transport, and to categorize, classify and assess the risk estimation of these events.Methods: Written comments in 1082 transport records during the period 1999–2011 were reviewed. Comments related to events that infringed on patient and staff safety were included as AEs, and categorized and further classified as complaint, imminent risk of incident/negative event, actual incident or actual negative event. AEs were also grouped into emergency or planned transports, and risk estimation was calculated according to a risk assessment tool and defined as low, intermediate, high or extreme risk.Results: AEs (N = 883) were divided into five categories: logistics (n = 337), organization (n = 177), equipment (n = 165), vehicle (n = 129) and medical/nursing care (n = 75). Eighty-five percent of AEs were classified as incidents or negative events. The majority of AEs were estimated to be of low or intermediate risk in both planned and emergency transports. AEs estimated to be of high or extreme risk were significantly more frequent in emergency transports (OR = 10.1; 95% CI: 5.0–20.9; p < 0.001).Conclusion: AEs are common in both planned and emergency neonatal transport, often related to imperfect transport logistics or equipment failure. AEs of high or extreme risk were more frequent in emergency transports.