A prospective review of adverse events during interhospital transfers of neonates by a dedicated neonatal transfer service

Pediatr Crit Care Med. 2008 May;9(3):289-93. doi: 10.1097/PCC.0b013e318172dbfd.


Objectives: To categorize and quantify adverse events occurring during emergency interhospital transfers performed by a specialized neonatal retrieval team and to assign levels of associated risk.

Design: Prospective review of adverse events during emergency interhospital transfers of neonates by the London Neonatal Transfer Service over a 6-month period. The events were categorized based on an adapted retrieval team model from the Paediatric & Neonatal Safe Transfer and Retrieval Course (PANSTAR). Risk levels were measured using a modified risk assessment score.

Setting: Emergency interhospital transfers by a specialized neonatal retrieval team.

Patients: Patients were 346 emergency neonatal transfers over 6 months.

Interventions: None.

Measurements and main results: We found that 125 transfers (36.1%) had at least one adverse event. There were 205 adverse events in total; 139 events (67%) were perceived as being due to avoidable human errors. Almost a third of events (30%) occurred even before the retrieval team arrived at the referring hospital and made contact with the patient. The largest group of events occurred due to problems in preparation (n = 69) and communication (n = 49). Most events (n = 143) had insignificant impacts on patients, but six events could have potentially caused major harm.

Conclusions: Adverse events commonly occur during neonatal transfers, even if performed by a dedicated transfer service. Early identification of potentially harmful episodes is important. Human error is likely to be a factor in the majority of adverse events; hence, opportunities should be taken to reduce the number of these through education, training, and risk management.

MeSH terms

  • Emergency Medical Services
  • Humans
  • Infant, Newborn
  • Medical Errors / statistics & numerical data*
  • Patient Transfer* / standards
  • Prospective Studies
  • Risk Assessment