(1276) Describing Adverse Outcomes for Patients Transferring to the Critical Care Resuscitation Unit

Introduction: The Critical Care Resuscitation Unit (CCRU) at the University of Maryland Medical Center is an Intensive Care Unit -based resuscitation unit with a mission of expediting interhospital transfers for critically ill patients requiring quaternary care. Despite the CCRU’s reduction in interhospital transfer time, little is known about the types of adverse events patients experience in the CCRU. We hypothesized that the incidence of adverse events related to the rapidity of transfer (coordination of care) would be greater than other single causes of adverse outcomes, such as medication errors, falls, hospital acquired infections (HAI), and procedural complications.

Methods: This retrospective observational study queried all adverse events that were submitted to our institution from 2016-2023 and ocurred in the CCRU. Adverse events included procedural complications, coordination errors from transferring hospital, and medication dispensing delays in critical patients.. Events were stratified by month, type, and correlated with harm

Results: We analyzed 882 adverse events over the period from 2016 to 2023 and found a mean of 10.26±5.38 per month. April and May 2020 contributed the largest number of monthly adverse events, 24 and 26, respectively. The most prevalent types of adverse events included those related to care coordination (180, 20.4%), medication errors (175, 19.8%), and laboratory/pathology errors (140, 15.9%). Adverse events related to diagnosis and treatment were most highly associated with major harm (27.8%, 10/36) while those related to care coordination were most highly associated with no harm (93.2%, 180/196).

Conclusions: Most adverse events occurring in the CCRU were related to coordination of care errors due to rapid transfers. Most events did not result in patient harm, yet this prevalence underscores the need for further data on the difference in adverse events between the CCRU and other critical care units and identification of modifiable risk factors to reduce adverse events.