Impact of Adverse Events on Neonatal Emergency Transport: Italian Experience.

Aim: To quantify and categorise retrospectively all adverse events occurring during unplanned neonatal emergency interhospital transfers conducted by the Transfer Service of the Spedali Civili di Brescia over 3 years.

Methods: The revised data were extracted from specific questionnaires filled out by staff. The events were classified according to an adapted retrieval team model (PANSTAR); the risk level was assessed using an effective risk assessment score.

Results: In 340 transports, 74 adverse events were identified; 68% of them were perceived as due to human error. Most of the events (82%) occurred during the second stage of transportation. One of the 74 events was described as a potential cause of major injury to the patient; 61 of the 74 events were considered insignificant. No event was considered potentially catastrophic.

Conclusion: Although most accidents do not pose a significant risk for the newborn, it is important to identify the few events that could potentially cause significant harm. Some phases of transportation are more at risk than others, and human error is confirmed as a predominant factor in most adverse events. Therefore, opportunities to reduce the number of events through education, training of neonatal retrieval teams and risk management should not be missed.