Danish Institute for Medical Simulation, Herlev Hospital, Capital Region of Denmark, Denmark; University of Copenhagen, Denmark.
Resuscitation. 2010 Mar;81(3):312-6. doi: 10.1016/j.resuscitation.2009.10.018. Epub 2009 Dec 22.
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.
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.
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%).
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.
严重医疗不良事件报告可识别复苏实践中的改进领域。丹麦患者安全数据库是一个强制性报告系统，接收医院人员提交的严重医疗不良事件报告。本研究旨在识别、分析和分类向丹麦患者安全数据库报告的与心脏骤停相关的严重医疗不良事件。
使用“心脏骤停”和“复苏”这两个检索词在丹麦患者安全数据库中识别报告。然后将识别出的严重医疗不良事件分类为不同的类别。
共确定了 107 份报告，描述了 122 个单独的事件，并将其分类为与以下方面相关的事件：复苏团队的警报（n=32；26%）、人为因素（n=22；18%）、设备故障（n=19；16%）、复苏设备不可用（n=13；11%）、物理环境（n=14；11%）、监测不足（n=14；11%）和用药错误（n=8；7%）。
心脏骤停相关的严重医疗不良事件是由于后勤、技术、团队合作和知识问题导致的。在规划教育和实施复苏实践时应考虑这些发现。
