| Inadequate written handover | A formal transfer form was used for each transfer, providing the following information: patient name, date of birth and medical record number, infectious status, destination, escort and equipment requirements, transport mode and patient's red dot status. An error occurred if the form was absent, or any information in the form was omitted or incorrect. |
| Failure to verify patient identification | The transfer protocol mandated a three-step identification check by the ward nurse on patient collection, and by Radiology on arrival. These steps were: verification of identification wrist band, verbal verification of patient's full name and verbal verification of patient's date of birth. An error is said to have occurred if any one of the steps was not performed. |
| Inadequate infection control precaution | Failure to take the appropriate infection control precautions when transporting an infectious patient. A patient was deemed to be infectious only if the researcher could verify the patient's infectious status through inspection of transfer form or verbal confirmation by the nurse caring for the patient. |
| Inadequate escort | Failure to provide clinical escort when patient was critically ill, when transporting patient with medical devices or when patient was incapable of communicating |
| Inadequate transport mode | Failure to provide transport mode (bed, trolley or chair) suited to the condition of the patient |
| Equipment failure | Devices accompanying patient malfunctioned during transfer |
| Poor organisation | Failure to ensure that the patient was ready for collection at the appointed time, or the resources required for transfer were unavailable |