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G119(P) Patientsafety incident reporting data trends of a regional neonatal transfer service
  1. SL Davidson1,
  2. N Ratnavel1,2,
  3. A Sinha1,2,3,
  4. S Mohinuddin1,2
  1. 1London Neonatal Transfer Service, Bart’s Health NHS Trust, London, UK
  2. 2Neonatal Unit of the Children’s Hospital Based at the Royal London Hospital, Bart’s Health NHS Trust, London, UK
  3. 3Centre for Paediatrics, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK


Introduction Neonatal transfers take place in a high-risk environment and patient safety must be a key priority.

Methods Risk reporting for this regional transfer service has evolved over the last five years. The patient safety incident form has been adapted over the last 3 years, providing a clear structure of what is to be reported, ensuring the significance of the adverse event is considered and the response to the incident recorded. This study reviewed the patient safety incident forms completed over the last three years.

Results Form completion significantly improved from 61% in 2011 to 96% in 2013. Comparing trends between 2012 and 2013: significant improvements were seen in delayed dispatch to time critical transfers, time delays during stabilisation, equipment problems, vascular incidents and unintended hypothermia. However, a significant increase in hypocarbia and endotracheal tube repositioning.

Conclusion We report improved risk reporting and an improvement in many of the incident categories. Future work needs to focus on sustaining and improving other categories.

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