Equipment falling onto critically ill patients during intrahospital transfers

Through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources, the National Patient Safety Team identified cases where equipment had fallen onto critically ill patients during intrahospital transfers.

A Serious Incident report described a ventilated patient being transported to theatre from the critical care unit. When the bed went over a bump in the corridor the transport ventilator fell off the stack and landed on the patient’s leg, and the patient sustained a fracture.

The team received information that most critical care intra-hospital transfers occur with patients in their beds with equipment attached to a stack or end of bed table, rather than on bespoke transfer trolleys.

The Faculty of Intensive Care Medicine agreed to help prevent further cases by highlighting the specific advice for intra-hospital transfers via its safety bulletin.

About our patient safety review and response work

The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare.

A core part of the work of the National Patient Safety Team is to review these records to identify new or under recognised patient safety risks, which are often not obvious at a local level. In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.

You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.

You can also find more case studies providing examples of this work on our case study page.