- Intrahospital transport of critically ill and anesthetized children is a high-risk phase of care, with respiratory and airway complications being the most frequent and often preventable events.
- This review describes 5 major error traps associated with the intrahospital transport of these patients, and identifies evidence-based countermeasures for each:
- Failure to weigh risks/costs/benefits: Multidisciplinary risk–benefit discussions should include anesthesiologists, intensivists, nurses, and consultants, considering alternatives such as bedside procedures.
- Failure to secure resources/personnel: Standardized checklists, equipment, and appropriately trained staff are essential. Preparation includes clustering care, simplifying infusions, and ensuring destination readiness.
- Failure to provide effective handoffs: Structured tools (e.g., SBAR, I-PASS) reduce information loss, prevent medication errors, and clarify anticipated complications.
- Failure to anticipate physiologic changes: Anticipating effects of ventilator transitions, patient positioning, medication administration, and environmental factors (e.g., hypothermia) can prevent instability and device dislodgement.
- Failure of teamwork/leadership: Leadership style should adapt to team experience and patient complexity. Directive leadership suits unstable patients or novice teams, while empowering leadership works with experienced teams.
- The review also notes the following regarding transport of critically ill and anesthetized children:
- Younger age and greater comorbidity burden increase risk.
- Most events are linked to anesthesia care and can be reduced by systematic planning, structured communication, and team-based strategies.
- Evidence supports multidisciplinary huddles, simulation-based training, and structured handoffs to improve safety.
- A strong institutional safety culture and adaptive leadership are associated with fewer adverse events.
- While most transport-related complications are preventable, ongoing research is needed to refine team training models specific to pediatric transport.
- The author concludes by asserting that intrahospital transport of critically ill children should be treated as a distinct perioperative phase with unique hazards. By incorporating risk assessment, resource optimization, standardized communication, and team-based leadership, anesthesia professionals can reduce preventable harm and strengthen patient safety.
Summary of "Error Traps in the Intrahospital Transport of Critically Ill and Anesthetized Children"
Summary published October 28, 2025
