A review of adverse events associated with perioperative intrahospital transport of pediatric patients and guidance on improving safety (June 2023)

Summary

Intrahospital transport is a common occurrence for many hospitalised patients. Critically ill children are an especially vulnerable population who experience preventable adverse events at least once a week, on average. Transporting these patients throughout the hospital introduces additional hazards and increases the risk of adverse events.

The transport process can be decomposed into a series of steps, each incurring specific risk. These risks are numerous and few of these risks are specific to the transport process. There is a paucity of literature available on paediatric intrahospital transport and related adverse events.

Elliot et al. recently reviewed the Wake Up Safe database, a paediatric anesthesia quality improvement initiative across member institutions to disseminate information on best practices, for paediatric perioperative adverse events associated with anaesthesia-directed transport. The authors present several examples of airway and respiratory events taken from the database and discuss the complexity of the transport process.