Safety through redundancy: a case study of in-hospital patient transfers -- Ong and Coiera -- Quality and Safety in Health Care

Qual Saf Health Care doi:10.1136/qshc.2009.035972
Original research
Safety through redundancy: a case study of in-hospital patient transfers
Mei-Sing Ong, Enrico Coiera
+ Author Affiliations

Centre for Health Informatics, University of New South Wales, Sydney, Australia

Correspondence to
Professor Enrico Coiera, Centre for Health Informatics, University of New South Wales, Sydney NSW 2052, Australia;e.coiera@unsw.edu.au

Accepted 7 January 2010
Published Online First 29 July 2010

Abstract
Objectives To study the extent and execution of redundant processes during inpatient transfers to Radiology, and their impact on errors during the transfer process; to explore the use of causal and reliability analyses for modelling error detection and redundancy in the transfer process; and to provide guidance on potential system improvements.

Methods A prospective observational study at a metropolitan teaching hospital. 101 patient transfers to Radiology were observed over a 6-month period, and errors in patient transfer process were recorded. Fault Tree Analysis was used to model error paths and identify redundant steps. Reliability Analysis was used to quantify system reliability.

Results 420 errors were noted, an average of four errors per transfer. No incidents of patient harm were recorded. Inadequate handover was the most common error (43.1%), followed by failure to perform patient identification checks (41.9%), patient inadequately prepared for transfer (7.4%), inadequate infection control precautions (2.9%), inadequate clinical escort (2.1%), inadequate transport vehicle (2.1%) and equipment failure (0.2%). Four redundant steps for communicating patients' infectious status were identified (reliability=0.07, 0.37, 0.26, 0.31). Collectively, these yielded a system reliability of 0.7. The low reliability of each individual step was due to its low rate of execution.

Conclusions Analysis of the transfer process revealed a number of redundancies that safeguard against transfer errors. However, they were relatively ineffective in preventing errors, due to the poor compliance rate. Thus, the authors advocate increasing compliance to existing redundant processes as an improvement strategy, before investing resources on new processes.
Safety through redundancy: a case study of in-hospital patient transfers -- Ong and Coiera -- Quality and Safety in Health Care