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Towards safer neonatal transfer: the importance of critical incident review

Lookup NU author(s): Professor Nicholas EmbletonORCiD, Dr Alan Fenton


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Background: Critical incidents are common during the inter-hospital transfer of sick patients, and infants are an especially vulnerable group. Aims: To examine the effect of critical incident review on the number of adverse events during inter-hospital transfer of sick infants. Methods: Critical incidents over an eight year period are reported from a single neonatal transfer service before and after major service changes were made. The changes were instigated as part of ongoing critical incident reviews. Results: Changes made as a result of critical incident review significantly reduced the number of incidents contributed to by poor preparation, transport equipment or clinical problems, ambulance delays, and ambulance equipment failure. Conclusions: The continuous process of critical incident reporting and review can reduce the number of adverse events during the transfer of critically ill infants.

Publication metadata

Author(s): Moss SJ, D Embleton N, Fenton AC

Publication type: Article

Publication status: Published

Journal: Archives of Disease in Childhood

Year: 2005

Volume: 90

Issue: 7

Pages: 729-732

ISSN (print): 0003-9888

ISSN (electronic): 1468-2044

Publisher: BMJ Group


DOI: 10.1136/adc.2004.066639


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