Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database☆
Received 20 August 2009; received in revised form 14 October 2009; accepted 18 October 2009. published online 21 December 2009.
Abstract
Background
Critical incident reports can identify areas for improvement in resuscitation practice. The Danish Patient Safety Database is a mandatory reporting system and receives critical incident reports submitted by hospital personnel. The aim of this study is to identify, analyse and categorize critical incidents related to cardiac arrests reported to the Danish Patient Safety Database.
Methods
The search terms “cardiac arrest” and “resuscitation” were used to identify reports in the Danish Patient Safety Database. Identified critical incidents were then classified into categories.
Results
One hundred and seven reports describing 122 separate incidents were identified and classified into incidents related to: alerting the resuscitation team (n=32; 26%), human performance (n=22; 18%), equipment failure (n=19; 16%), resuscitation equipment not available (n=13; 11%), physical environment (n=14; 11%), insufficient monitoring (n=14; 11%), and medication error (n=8; 7%).
Conclusion
Critical incidents related to cardiac arrest occur due to logistical, technical, teamworking and knowledge problems. These findings should be considered when planning education and implementing resuscitation practice.
ABSTRACT