Resuscitation
Volume 81, Issue 3 , Pages 312-316 , March 2010

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

  • Peter Oluf Andersen

      Affiliations

    • Danish Institute for Medical Simulation, Herlev Hospital, Capital Region of Denmark, Denmark
    • University of Copenhagen, Denmark
    • Corresponding Author InformationCorresponding author at: Danish Institute for Medical Simulation, Herlev Hospital, Herlev Ringvej 75, DK 2730 Herlev, Denmark.
  • ,
  • Rikke Maaløe

      Affiliations

    • Department of Anaesthesiology, Bispebjerg Hospital, Capital Region of Denmark, Denmark
    • University of Copenhagen, Denmark
  • ,
  • Henning B. Andersen

      Affiliations

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

Received 20 August 2009 ,Revised 14 October 2009 ,Accepted 18 October 2009.

References 

  1. Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA. 2005;293:305–310
  2. Marsch SC, Tschan F, Semmer N, Spychiger M, Breuer M, Hunziker PR. Unnecessary interruptions of cardiac massage during simulated cardiac arrests. Eur J Anaesthesiol. 2005;22:831–833
  3. Iirola T, Lund VE, Katila AJ, Mattila-Vuori A, Palve H. Teaching hospital physicians’ skills and knowledge of resuscitation algorithms are deficient. Acta Anaesthesiol Scand. 2002;46:1150–1154
  4. Battles JB, Stevens DP. Adverse event reporting systems and safer healthcare. Qual Saf Health Care. 2009;18:2
  5. Wu AW, Pronovost P, Morlock L. ICU incident reporting systems. J Crit Care. 2002;17:86–94
  6. Holden RJ, Karsh BT. A review of medical error reporting system design considerations and a proposed cross-level systems research framework. Hum Factors. 2007;49:257–276
  7. Hales BM, Pronovost PJ. The checklist—a tool for error management and performance improvement. J Crit Care. 2006;21:231–235
  8. Danish act on Patient Safety (english translation); 2009. Ref Type: Bill/Resolution.
  9. The Danish Society for Patient Safety, et al. Patient safety in Denmark: past, current and future activities; 2005. Ref Type: Report.
  10. Capital Region. Utilsigtede Haendelser ved hjertestop (Adverse events in connection with cardiac arrest, in Danish); 2007. Ref Type: Report.
  11. Cooper S, Wakelam A. Leadership of resuscitation teams: “Lighthouse Leadership’. Resuscitation. 1999;42:27–45
  12. Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med. 2000;343:1206–1209
  13. Chan PS, Krumholz HM, Nichol G, Nallamothu BK. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358:9–17
  14. Nolan J, Soar J, Eikeland H. The chain of survival. Resuscitation. 2006;71:270–271
  15. Abbas G, Alfonzo A, Arntz H, et al. Advanced life support algorithm. In:  Nolan J,  Gabbot D,  Lockey A, et al. editor. Advanced life support. 5th ed.. Antwerp, Belgium: European Resuscitation Council; 2006;p. 38–39
  16. O’Connor R, Weil M. Crocco tea. Effective resuscitation team dynamics. In:  Field J editors. Advanced cardiovascular life support. American Heart Association; 2006;p. 11–18
  17. DeVita MA, Schaefer J, Lutz J, Wang H, Dongilli T. Improving medical emergency team (MET) performance using a novel curriculum and a computerized human patient simulator. Qual Saf Health Care. 2005;14:326–331
  18. Schaefer HG, Helmreich RL, Scheidegger D. Human factors and safety in emergency medicine. Resuscitation. 1994;28:221–225
  19. Flin RH, O’Connor P, Crichton M. Safety at the sharp end: a guide to non-technical skills. Aldershot, England: Ashgate; 2008;
  20. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000;320:745–749
  21. Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand. 2009;53:143–151
  22. Salas E, DiazGranados D, Weaver SJ, King H. Does team training work? Principles for health care. Acad Emerg Med. 2008;15:1002–1009
  23. Marsch SC, Muller C, Marquardt K, Conrad G, Tschan F, Hunziker PR. Human factors affect the quality of cardiopulmonary resuscitation in simulated cardiac arrests. Resuscitation. 2004;60:51–56
  24. Wickens C. Designing for stress. In:  Driskell JE,  Salas E editor. Stress and human performance. Mahwah, NJ: Erlbaum; 1996;p. 279–295
  25. Karsh BT, Scanlon M. When is a defibrillator not a defibrillator? When it's like a clock radio… The challenge of usability and patient safety in the real world. Ann Emerg Med. 2007;50:433–435
  26. Hillman K, Chen J, Cretikos M, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005;365:2091–2097
  27. Sari AB-A, Sheldon TA, Cracknell A, Turnbull A. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ. 2007;334:79

 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

Resuscitation
Volume 81, Issue 3 , Pages 312-316 , March 2010