TY - JOUR T1 - Towards safer neonatal transfer: the importance of critical incident review JF - Archives of Disease in Childhood JO - Arch Dis Child SP - 729 LP - 732 DO - 10.1136/adc.2004.066639 VL - 90 IS - 7 AU - S J Moss AU - N D Embleton AU - A C Fenton Y1 - 2005/07/01 UR - http://adc.bmj.com/content/90/7/729.abstract N2 - Background: Critical incidents are common during the inter-hospital transfer of sick patients, and infants are an especially vulnerable group. Aims: To examine the effect of critical incident review on the number of adverse events during inter-hospital transfer of sick infants. Methods: Critical incidents over an eight year period are reported from a single neonatal transfer service before and after major service changes were made. The changes were instigated as part of ongoing critical incident reviews. Results: Changes made as a result of critical incident review significantly reduced the number of incidents contributed to by poor preparation, transport equipment or clinical problems, ambulance delays, and ambulance equipment failure. Conclusions: The continuous process of critical incident reporting and review can reduce the number of adverse events during the transfer of critically ill infants. ER -