Error Traps in the Intrahospital Transport of Critically Ill and Anesthetized Children.

Abstract

Intrahospital transport of anesthetized and critically ill children is a routine event that carries myriad risks. Patients with a vast array of conditions are transported between the intensive care unit, procedural and diagnostic imaging suites, emergency department, and other areas. Given this complexity, the range of potential adverse events is large. Improving safety during transport will require a broad and holistic approach. This review will inform pediatric anesthesiologists on the best approach to improve their care and patient safety during transport by identifying common error traps, with both individual- and system-level countermeasures. The error traps include the failure to fully weigh all risks, costs, and benefits associated with transport for a procedure or test; secure appropriate resources for transport and at every destination; provide pertinent information during transfers of care; anticipate physical and physiological changes associated with transport; and execute the plan effectively as a team. Countermeasures include multidisciplinary discussion and resource optimization; use of systematic tools, standardized communication, and checklists to improve processes of care; encouraging the prioritization of a culture of safety around transport; and adapting the team composition and leadership style to suit the specific clinical scenario.