Children undergoing intrahospital transport are at risk for adverse events. This study used perioperative adverse event data reported to a patient safety organization to identify pediatric anesthesia transport-associated adverse events. A small proportion (5%) of pediatric anesthesia adverse events were associated with transport, but the majority of events were deemed preventable and one-third resulted in patient harm. Cardiac arrest and respiratory events occurred most frequently and largely affected very young children (<6 month). A previous WebM&M discussed a perioperative respiratory event in a pediatric patient during intrahospital transport.

Incomplete handoffs and poor communication regarding key clinical information may lead to adverse events or missed or delayed diagnoses. This systematic review sought to determine effective interventions to enhance nursing handoffs. Although several studies have examined handoff techniques that nurses used, there is no evidence to indicate whether verbal handoffs, chart-based handoffs, or handoffs including patients or family are associated with improved patient outcomes, echoing a prior systematic review. The authors recommend that nursing handoffs be structured, include face-to-face communication, involve patients, and utilize health information technology. They also call for studies to compare different approaches in order to achieve an evidence-based best practice. A past AHRQ WebM&M commentary describes the consequences of an incomplete nursing handoff.