Clinical PaperImpact of resuscitation system errors on survival from in-hospital cardiac arrest☆
Introduction
The Institutes of Medicine (IOM) landmark publication (“To Err is Human”) estimated that at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors.1 Although the magnitude of the problem has been questioned,2 the Canadian Adverse Events (AE) Study confirms an alarming frequency of in-hospital AEs (7.5 per 100 hospital admissions; 95% confidence interval [CI], 5.7–9.3), 36.9% (95% CI, 32.0–41.8%) of which are potentially preventable. Death occurred in 20.8% (95% CI, 7.8–33.8%) of cases.
The American Heart Association (AHA) Get with the Guidelines National Registry of Cardiopulmonary Resuscitation (NRCPR) collects data on adult and pediatric in-hospital cardiac arrest (IHCA) events from approximately 10% of hospitals in the United States.3 From this registry, NRCPR investigators have documented lower survival from adult in-hospital cardiac arrest (1) on nights and weekends likely due, at least in part, to system factors,3 (2) when defibrillation is delayed greater than 2 min in patients whose initial IHCA rhythm is ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT),4 and (3) in certain hospital locations.5
The purpose of this paper was to determine whether the presence of resuscitation system errors reported to NRCPR are associated with lower likelihood of survival in adult patients who experience an IHCA.
Section snippets
Data collection and integrity
NRCPR is a prospective, observational, multi-center performance improvement registry of IHCA events. Hospitals join voluntarily and pay an annual fee for data support and report generation.
Hospital medical records on sequential IHCA events are abstracted by trained, NRCPR-certified, performance improvement personnel at each participating institution. All data elements have standardized definitions allowing aggregate data analysis from multiple sites, and all data transfer is in compliance with
Results
A total of 118,387 in-hospital, adult, index IHCA cases were entered into the NRCPR database from January 1, 2000 through August 26, 2008. Of these, 84,440 (71.3%) had no system errors recorded and 33,947 (28.7%) had one or more system errors recorded. Of the cases with system errors, 26,919 (22.7%) had 1 error, 5614 (4.7%) had 2 system errors, and 1414 (1.2%) had 3 or more system errors. Of all cases in which the initial rhythm was recorded, 84,169/108,636 (77.5%) had non VF/pVT and
Discussion
The principal finding in this study is that the presence of resuscitation system errors is associated with decreased survival from IHCA in adults. More errors were noted in patients whose initial documented IHCA rhythm was VF/pVT as opposed to those with non-shock-able rhythms. This finding is particularly relevant clinically, given that the majority of survivors of IHCA are those with initial VF/pVT.3
Our findings, although much broader, support those reported by Chan et al.4 who evaluated 6789
Conclusions
We conclude that the presence of resuscitation system errors that are evident from review of the resuscitation record is associated with decreased survival from IHCA in adults. Hospitals should target their training of first responders and code team personnel to emphasize the importance of early defibrillation when indicated, early use of vasoconstrictor medication, and compliance with established AHA ACLS resuscitation protocols.
Conflict of interest statement
None of the authors have any relevant conflicts.
Funding sources
None.
Acknowledgement
None.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.09.009.
- c
For the American Heart Association's Get With the Guidelines – Resuscitation (National Registry of Cardiopulmonary Resuscitation) Investigators, see Appendix A.