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Volume 81, Issue 3, Pages 312-316 (March 2010)


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Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database

Peter Oluf AndersenadCorresponding Author Informationemail address, Rikke Maaløebdemail address, Henning B. Andersencemail address

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.

a Danish Institute for Medical Simulation, Herlev Hospital, Capital Region of Denmark, Denmark

b Department of Anaesthesiology, Bispebjerg Hospital, Capital Region of Denmark, Denmark

c Department of Management Engineering, Technical University of Denmark, Denmark

d University of Copenhagen, Denmark

Corresponding Author InformationCorresponding author at: Danish Institute for Medical Simulation, Herlev Hospital, Herlev Ringvej 75, DK 2730 Herlev, Denmark.

 A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.10.018.

PII: S0300-9572(09)00547-4

doi:10.1016/j.resuscitation.2009.10.018


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