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

Peter Oluf Andersen, Rikke Maaløe, Henning Boje Andersen

    Research output: Contribution to journalJournal articleResearchpeer-review

    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.
    Original languageEnglish
    JournalResuscitation
    Volume8
    Pages (from-to)312-316
    ISSN0300-9572
    DOIs
    Publication statusPublished - 2010

    Keywords

    • Critical incidents
    • Cardiac arrest
    • Resuscitation

    Cite this

    @article{22f9dd60d12e4f36953277b3b22034fb,
    title = "Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database",
    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.",
    keywords = "Critical incidents, Cardiac arrest, Resuscitation",
    author = "Andersen, {Peter Oluf} and Rikke Maal{\o}e and Andersen, {Henning Boje}",
    year = "2010",
    doi = "10.1016/j.resuscitation.2009.10.018",
    language = "English",
    volume = "8",
    pages = "312--316",
    journal = "Resuscitation",
    issn = "0300-9572",
    publisher = "Elsevier",

    }

    Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database. / Andersen, Peter Oluf; Maaløe, Rikke; Andersen, Henning Boje.

    In: Resuscitation, Vol. 8, 2010, p. 312-316.

    Research output: Contribution to journalJournal articleResearchpeer-review

    TY - JOUR

    T1 - Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database

    AU - Andersen, Peter Oluf

    AU - Maaløe, Rikke

    AU - Andersen, Henning Boje

    PY - 2010

    Y1 - 2010

    N2 - 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.

    AB - 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.

    KW - Critical incidents

    KW - Cardiac arrest

    KW - Resuscitation

    U2 - 10.1016/j.resuscitation.2009.10.018

    DO - 10.1016/j.resuscitation.2009.10.018

    M3 - Journal article

    C2 - 20022417

    VL - 8

    SP - 312

    EP - 316

    JO - Resuscitation

    JF - Resuscitation

    SN - 0300-9572

    ER -