Have a safe journey.

Abstract

In the modern era of reliable communication systems and relatively safe modes of transport the wish - “have a safe journey” still has relevance. The article by Venkategowda in this issue of the journal[1] shows that even short journeys inside the hospital are commonly eventful. Prior publications in India have addressed related issues in neonates from distant places to hospital, and a high mortality associated with transfer has been reported.[2] Patients are older and sicker; there is more need for imaging studies, and hence transport to and from intensive care unit (ICU) has increased. In mechanically ventilated patients, transport out of ICU for diagnostic purposes is common; transfer rates up to 52% have been reported[3] and have been associated with increasing risks of ventilator associated pneumonia. The current article reports an unexpected event (UE) rate of one for every four patient transfers and some patients had more than one UE. Most UEs were of a minor nature and none were life threatening. A similar larger exercise has been reported from Australian ICUs from the years 1993 to 1999.[4] The strength of this study was that incident reports were in an anonymous fashion, which could have led to greater capture of all events. An attempt was also made in the study to classify the factors contributing to the errors as system-based and human-based errors. The message of the current study would have been strengthened if the cause of the UE's could have been apportioned to training, protocol violation, procedural skill, and communication issues. Medical training in India and elsewhere has, for too long, paid undue emphasis on individual skill development in diagnostic and procedural tasks. It is assumed that with the acquisition of these skills, high quality processes and good outcomes will naturally follow. The “watch one, do one, and teach one” motto[5] in residency training has not been replaced with formal assessment and supervised training in complex simulated ICU conditions. All of this has acquired increasing relevance due to the complexity of cases, and increasing number of patients requiring intensive care and its associated procedures. An ICU patient may require 178 individual tasks per day each of which is prone to error.[6] Safety and quality in medicine has been shown to improve after following principles first adopted in aircraft engineering. The checklist approach has been documented to improve outcomes in intensive care.[6] For a checklist approach to work, baseline data has to be captured. The current study is a first step in the acquisition of data with respect to the safety of intrahospital transport in ICU patients. Larger studies of anonymous reports with standard formats of error classification will aid in the development of efficient protocols and benchmarks for the safe transport of ICU patients.