Document Detail


Errors in the management of cardiac arrests: An observational study of patient safety incidents in England.
MedLine Citation:
PMID:  25449347     Owner:  NLM     Status:  Publisher    
Abstract/OtherAbstract:
OBJECTIVE: The aim of this qualitative study is to better understand the types of error occurring during the management of cardiac arrests that led to a death.
METHODS: All patient safety incidents involving management of cardiac arrests and resulting in death which were reported to a national patient safety database over a 17-month period were analysed. Structured data from each report were extracted and these together with the free text, were subjected to content analysis which was inductive, with the coding scheme emerged from continuous reading and re-reading of incidents.
RESULTS: There were 30 patient safety incidents involving management of cardiac arrests and resulting in death. The reviewers identified a main shortfall in the management of each cardiac arrest and this resulted in 12 different factors being documented. These were grouped into four themes that highlighted systemic weaknesses: miscommunication involving crash number (4/30, 13%), shortfalls in staff attending the arrest (4/30, 13%), equipment deficits (11/30, 36%), and poor application of knowledge and skills (11/30, 37%).
CONCLUSION: The factors identified represent serious shortfalls in the quality of response to cardiac arrests resulting in death in hospital. No firm conclusion can be drawn about how many deaths in the study population would have been averted if the emergency had been managed to a high standard. The effective management of cardiac arrests should be considered as one of the markers of safe care within a healthcare organisation.
Authors:
Sukhmeet S Panesar; Agnieszka M Ignatowicz; Liam J Donaldson
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Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2014-10-17
Journal Detail:
Title:  Resuscitation     Volume:  85     ISSN:  1873-1570     ISO Abbreviation:  Resuscitation     Publication Date:  2014 Oct 
Date Detail:
Created Date:  2014-12-2     Completed Date:  -     Revised Date:  2014-12-3    
Medline Journal Info:
Nlm Unique ID:  0332173     Medline TA:  Resuscitation     Country:  -    
Other Details:
Languages:  ENG     Pagination:  1759-1763     Citation Subset:  -    
Copyright Information:
Copyright © 2014. Published by Elsevier Ireland Ltd.
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