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Vol. 46. Issue 1.
Pages 14-22 (January 2022)
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Vol. 46. Issue 1.
Pages 14-22 (January 2022)
Incidents related to critical patient safety during in-hospital transfer
Incidentes relacionados con la seguridad del paciente crítico durante los traslados intrahospitalarios
R.M. Catalán-Ibarsa,b, M.C. Martín-Delgadoc,d,
Corresponding author

Corresponding author.
, E. Puigoriol-Juvantenyb,e, E. Zapater-Casanovaa, M. Lopez-Alaberna, J.L. Lopera-Caballeroa, J.P. González de Velascoa, M. Coll-Solàa, M. Juanola-Codinaa, N. Roger-Casalse,f
a Unidad de Cuidados Intensivos, Hospital Universitario de Vic-Consorcio Hospitalario de Vic, Spain
b Facultad de Ciencias de la Salud y Bienestar, Universidad de Vic-Central de Cataluña, Spain
c Servicio de Medicina Intensiva, Hospital Universitario de Torrejón, Madrid, Spain
d Facultad de Medicina, Universidad Francisco de Vitoria (UFV), Madrid, Spain
e Transferencia de Conocimiento, Hospital Universitario de Vic-Consorcio Hospitalario de Vic, Spain
f Facultad de Medicina, Universidad de Vic-Central de Cataluña, Spain
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Figures (3)
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Tables (4)
Table 1. Checklist before in-hospital transfer.
Table 2. Description of adverse events.
Table 3. Risk factors associated with the appearance of incidents related to patient safety during in-hospital transfers of critically ill patients at the ICU setting.
Table 4. Multivariate risk factors associated with the appearance of incidents related to patient safety during in-hospital transfers of critically ill patients at the ICU setting.
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To analyze the incidents related to patient safety (IRSP) and their risk factors during in-hospital transfer (IHT) of critical patients after the application of a protocol, and to evaluate safety during transfer using quality indicators.


A prospective, observational and non-intervention cohort study was carried out.


A 10-bed multipurpose Intensive Care Unit (ICU) of a second level university hospital.


All IHTs of critical patients in the ICU for diagnostic tests and to the operating room between March 2011 and March 2017 were included in the study.

Main measurements

Demographic variables, patient severity, transfer priority, moment of the day, reason and type of transfer team. Pre-transport checklist items and IRSP were collected. A biannual analysis was made of quality indicators designed for IHT.


A total of 805 transfers were registered, mostly of an urgent nature (53.7%) and for diagnostic tests (77%). In turn, 112 transfers (13.9%) presented some type of IRSP; 54% related to the equipment and 30% related to team and organization. Adverse events occurred in 19 (2.4%) transfers. Risk factors identified in the multivariate analysis were mechanical ventilation and the transport team. The evolution of the indicators related to transport was significantly favorable.


After the application of an IHT protocol, IRSP are low. The main risk factor is invasive mechanical ventilation. The experience of the team performing IHT influences the detection of a greater number of incidents.

In-hospital transfer
Incidents related to patient safety
Quality indicators
Adverse events
Critical patient safety

Analizar los incidentes relacionados con la seguridad del paciente (IRSP) durante los traslados intrahospitalarios (TIH) del paciente crítico tras la aplicación de un protocolo, así como sus factores de riesgo. Evaluar la seguridad durante los traslados mediante indicadores de calidad.


Estudio de cohorte, prospectivo, observacional y no intervencionista.


Unidad de Cuidados Intensivos (UCI) polivalente de 10 camas de un hospital universitario de segundo nivel.


Se incluyen todos los TIH de pacientes críticos realizados de UCI a pruebas diagnósticas y a quirófano entre marzo de 2011 y marzo de 2017.

Principales variables del estudio

Variables demográficas, gravedad de los pacientes, prioridad del traslado, momento del día, motivo y tipo de equipo del traslado. Se recogen comprobaciones pre-traslado e IRSP. Análisis semestral de indicadores de calidad diseñados para el TIH.


De los 805 traslados registrados, la mayoría urgentes (53,7%) y para pruebas diagnósticas (77%), 112 traslados (13,9%) presentaron algún tipo de IRSP, 54% relacionado con el equipamiento y 30% con el equipo y la organización. En 19 (2,4%) traslados se produjeron eventos adversos. En el análisis multivariante los factores de riesgo fueron la ventilación mecánica y el equipo que realiza el traslado. La evolución de los indicadores relacionados con los traslados es significativamente favorable.


Tras la aplicación de un protocolo de TIH, los IRSP son bajos y el principal factor de riesgo es la ventilación mecánica invasiva. La experiencia del equipo que realiza el TIH influye en la detección de un mayor número de incidentes.

Palabras clave:
Traslado intrahospitalario
Incidentes relacionados con la seguridad del paciente
Indicadores de Calidad
Eventos adversos
Seguridad del paciente crítico


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