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PSNet: Patient Safety Network
Journal Article

Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care.

Bapoje SR, Gaudiani JL, Narayanan V, et al. Journal of hospital medicine. 2011;6:68-72.

Patients should improve, not worsen, after hospital admission, and therefore safety interventions such as rapid response teams (RRTs) have been developed specifically to detect and manage unexpected clinical deterioration. This retrospective review of 152 unplanned transfers to the intensive care unit (ICU) at a teaching hospital found that only 15% of unplanned transfers could have been prevented by different management after admission. The most common reason for unplanned ICU transfer was incorrect triage (i.e., the patient should have been admitted directly to the ICU from the emergency department). This study challenges the utility of RRTs in preventing adverse clinical outcomes, and instead identifies the emergency department–inpatient handover as a possible area of focus for quality improvement interventions.