A 6-Year Thematic Review of Reported Incidents Associated With Cardiopulmonary Resuscitation Calls in a United Kingdom Hospital.

Abstract

Critical incident reporting can be applied to cardiopulmonary resuscitation (CPR) events as a means of reducing further occurrences. We hypothesized that local CPR-related events might follow patterns only seen after a long period of analysis. We reviewed 6 years of local incidents associated with cardiac arrest calls. The following search terms were used to identify actual or potential resuscitation events: "resuscitation," "cardio-pulmonary," "CPR," "arrest," "heart attack," "DNR," "DNAR," "DNACPR," "Crash," "2222." All identified incidents were independently reviewed and categorized, looking for identifiable patterns. Nottingham University Hospitals is a large UK tertiary referral teaching hospital. A total of 1017 reports were identified, relating to 1069 categorizable incidents. During the same time, there were approximately 1350 cardiac arrest calls, although it should be noted that many arrest-related incidents were not associated with cardiac arrest call (e.g., failure to have the correct equipment available in the event of a cardiac arrest). Incidents could be broadly classified into 10 thematic areas: no identifiable incident (n = 189; 18%), failure to rescue (n = 133; 12%), staffing concerns (n = 134; 13%), equipment/drug concerns (n = 133; 12%), communication issues (n = 122; 10%), do-not-attempt-CPR decisions (n = 101; 9%), appropriateness of patient location or transfer (n = 96; 9%), concerns that the arrest may have been iatrogenic (n = 76; 7%), patient or staff injury (n = 43; 4%), and miscellaneous (n = 52; 5%). Specific patterns of events were seen within each category. By reviewing incidents, we were able to identify patterns only noticeable over a long time frame, which may be amenable to intervention. Our findings may be generalizable to other centers or encourage others to undertake this exercise themselves.