Resuscitation 83 (2012) 63 69
Contents lists available at SciVerse ScienceDirect
Resuscitation
jo u rn al hom epage : www.elsevier.com/locate/resuscitation
Clinical Paper
Impact of resuscitation system errors on survival from in-hospital cardiac arrest
Joseph P. Ornatoa,", Mary Ann Peberdya,b, Renee D. Reida, V. Ramana Feesera, Harinder S. Dhindsaa, for
the NRCPR Investigatorsc
a
Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA, United States
b
Department of Internal Medicine & Emergency Medicine, Virginia Commonwealth University, Richmond, VA, United States
a r t i c l e i n f o a b s t r a c t
Article history:
Background: An estimated 350,000 750,000 adult, in-hospital cardiac arrest (IHCA) events occur annually
Received 14 May 2011
in the United States. The impact of resuscitation system errors on survival during IHCA resuscitation has
Received in revised form 9 September 2011
not been evaluated. The purpose of this paper was to evaluate the impact of resuscitation system errors
Accepted 11 September 2011
on survival to hospital discharge after IHCA.
Methods and results: We evaluated subjective and objective errors in 118,387 consecutive, adult, index
IHCA cases entered into the Get with the Guidelines National Registry of Cardiopulmonary Resuscitation
Keywords:
database from January 1, 2000 through August 26, 2008. Cox regression analysis was used to determine
Inhospital
the relationship between reported resuscitation system errors and other important clinical variables and
Resuscitation
the hazard ratio for death prior to hospital discharge. Of the 108,636 patients whose initial IHCA rhythm
Quality
was recorded, resuscitation system errors were committed in 9,894/24,467 (40.4%) of those with an ini-
Outcomes
Errors tial rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) and in 22,599/84,169
(26.8%) of those with non-VF/pVT. The most frequent system errors related to delay in medication admin-
istration (>5 min time from event recognition to first dose of a vasoconstrictor), defibrillation, airway
management, and chest compression performance errors. The presence of documented resuscitation
system errors on an IHCA event was associated with decreased rates of return of spontaneous circu-
lation, survival to 24 h, and survival to hospital discharge. The relative risk of death prior to hospital
discharge based on hazard ratio analysis was 9.9% (95% CI 7.8, 12.0) more likely for patients whose ini-
tial documented rhythm was non-VF/pVT when resuscitation system errors were reported compared to
when no errors were reported. It was 34.2% (95% CI 29.5, 39.1) more likely for those with VF/pVT.
Conclusions: 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 the training of
first responders and code team personnel to emphasize the importance of early defibrillation, early use
of vasoconstrictor medication, and compliance with ACLS protocols.
© 2011 Elsevier Ireland Ltd. All rights reserved.
1. Introduction questioned,2 the Canadian Adverse Events (AE) Study confirms
an alarming frequency of in-hospital AEs (7.5 per 100 hospital
The Institutes of Medicine (IOM) landmark publication ( To Err admissions; 95% confidence interval [CI], 5.7 9.3), 36.9% (95% CI,
is Human ) estimated that at least 44,000 and perhaps as many as 32.0 41.8%) of which are potentially preventable. Death occurred
98,000 Americans die in hospitals each year as a result of med- in 20.8% (95% CI, 7.8 33.8%) of cases.
ical errors.1 Although the magnitude of the problem has been The American Heart Association (AHA) Get with the Guidelines
National Registry of Cardiopulmonary Resuscitation (NRCPR) col-
lects data on adult and pediatric in-hospital cardiac arrest (IHCA)
events from approximately 10% of hospitals in the United States.3

A Spanish translated version of the abstract of this article appears as Appendix
From this registry, NRCPR investigators have documented lower
in the final online version at doi:10.1016/j.resuscitation.2011.09.009.
survival from adult in-hospital cardiac arrest (1) on nights and
"
Corresponding author at: Department of Emergency Medicine, Virginia Com-
weekends likely due, at least in part, to system factors,3 (2) when
monwealth University, 1250 East Marshall Street  Main Hospital 2nd Floor, Suite
500, Richmond, VA 23298-0401, United States. Tel.: [phone]; fax: +1 804 defibrillation is delayed greater than 2 min in patients whose ini-
828 8590.
tial IHCA rhythm is ventricular fibrillation or pulseless ventricular
E-mail address: [e-mail] (J.P. Ornato).
tachycardia (VF/pVT),4 and (3) in certain hospital locations.5
c
For the American Heart Association s Get With the Guidelines  Resuscitation
The purpose of this paper was to determine whether the
(National Registry of Cardiopulmonary Resuscitation) Investigators, see
presence of resuscitation system errors reported to NRCPR are
Appendix A.
0300-9572/$  see front matter © 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.resuscitation.2011.09.009
64 J.P. Ornato et al. / Resuscitation 83 (2012) 63 69
associated with lower likelihood of survival in adult patients who resuscitation members. Types of error categories included alert-
experience an IHCA. ing hospital-wide resuscitation response, airway management,
vascular access, chest compression, defibrillation, medications,
leadership, protocol deviation, and equipment function issues, with
2. Methods
specific subcategories listed in Table 1. Each type of individual error
had a checkbox that was to be filled in by the data abstractor if
2.1. Data collection and integrity
supported by the code record and/or hospital chart documenta-
tion, or conveyed by personnel on scene. For analysis of this data,
NRCPR is a prospective, observational, multi-center perfor-
one point was assigned for each individual error box checked on a
mance improvement registry of IHCA events. Hospitals join
given IHCA event. We totaled the number of cases with individual
voluntarily and pay an annual fee for data support and report gen-
system errors and created subtotals for the various types of errors
eration.
to calculate the number of cases in which any error occurred and
Hospital medical records on sequential IHCA events are
to catalogue and quantify the specific types of errors that occurred.
abstracted by trained, NRCPR-certified, performance improvement
We counted and added one point on each case for each NRCPR
personnel at each participating institution. All data elements have
 process of care exception error defined as: (1) delay of >5 min
standardized definitions allowing aggregate data analysis from
from IHCA event recognition to the first dose of a vasoconstric-
multiple sites, and all data transfer is in compliance with the Health
tor (epinephrine or vasopressin) on events that had a duration of
Insurance Portability and Accountability Act. Oversight for opera-
>5 min; or (2) delay of >2 min from IHCA event recognition to the
tions is provided by the American Heart Association, a scientific
first defibrillation shock in patients whose initial documented IHCA
advisory board, and an executive database steering committee.
rhythm was VF/pVT.  Resuscitation system errors were defined
Multiple efforts are taken to assure data integrity, including data
as the total number of reported system errors plus the number of
abstractor certification prior to allowing data entry, over 300 soft-
 process of care exceptions in each case. When the process of care
ware checks and smart skips to assist with accurate data entry, and
exception matched a self reported error (e.g., delay in time to first
ongoing abstractor training with monthly user s group calls and an
shock, time to first vasoconstrictor administration), only one point
annual user s group conference. Even though the most challeng-
was assigned for the error to avoid double counting.
ing data points to collect during resuscitation are event times and
intervals, these are documented in a high percentage of cases in
NRCPR hospitals. For example, in this analysis the time intervals
2.5. Statistical analysis
from IHCA onset to start of CPR and first vasopressor administra-
tion were captured in 89% and 76%, respectively. Further details of
All data analyses were performed using PASW Statistics ver-
the NRCPR database and data integrity can be found in previous
sion 17.0.2 (SPSS, Inc., Chicago, IL). Chi square and 95% confidence
publications.6,7
intervals were used for comparison of descriptive variables. ANOVA
using Scheffe s test for multiple comparisons was used to analyze
2.2. Study outcomes the relationship between 0, 1, 2, 3 or more errors and outcome
variables. Cox regression analysis was used to determine the rela-
The primary study outcome was survival to hospital discharge. tionship between reported resuscitation system errors as well as
Secondary outcomes were return of spontaneous circulation other important clinical variables and the hazard ratio for death
(ROSC) and survival for 24 h after IHCA. prior to hospital discharge. The status of the primary outcome
(i.e., life or death) was ascertained at three time points follow-
ing resuscitation: (1) whether ROSC occurred; (2) 24 h following
2.3. Inclusion/exclusion criteria
the IHCA event; and (3) at hospital discharge. Cox regression anal-
ysis was also used to determine the hazard ratio for the time of
The current analysis includes all consecutive, adult (age
day (day/evening or 7a 11p vs. night or 11p 7a) and day of week
e"18 years), initial, pulseless IHCA events entered from 549 dif-
(weekday or M F, weekend or S Su) on the reporting of resuscita-
ferent hospitals from January 1, 2000 through August 26, 2008.
tion system errors during a IHCA event.
All adults (e"18 years of age) who experienced an in-hospital
resuscitation event and who had documentation of initial heart
rhythm were eligible for inclusion. An event is defined as: (1)
3. Results
cardiopulmonary arrest requiring chest compressions and/or defib-
rillation, or (2) acute respiratory compromise requiring emergency
A total of 118,387 in-hospital, adult, index IHCA cases were
assisted ventilation leading to cardiopulmonary arrest requiring
entered into the NRCPR database from January 1, 2000 through
chest compressions and/or defibrillation. All events must also elicit
August 26, 2008. Of these, 84,440 (71.3%) had no system errors
a resuscitation response by facility personnel and have a resusci-
recorded and 33,947 (28.7%) had one or more system errors
tation record completed. Events are excluded if the arrest begins
recorded. Of the cases with system errors, 26,919 (22.7%) had
outside of the hospital, is limited to a shock delivered by an
1 error, 5614 (4.7%) had 2 system errors, and 1414 (1.2%)
implanted cardioverter-defibrillator (ICD), or occurs on a patient
had 3 or more system errors. Of all cases in which the initial
with a pre-existing do not attempt resuscitation order. For patients
rhythm was recorded, 84,169/108,636 (77.5%) had non VF/pVT
having multiple IHCA events during the same hospitalization, only
and 24,467/108,636 (22.5%) had VF/pVT. Errors were committed in
the first event was analyzed.
22,599/84,169 (26.8%) of non VF/pVT, and in 9894/24,467 (40.4%)
of those with VF/pVT as the first documented rhythm.
2.4. Categorization and counting of resuscitation system error The distribution of system errors for all IHCA patients by cate-
types gory is noted in Table 1. The most frequent system errors related
to delay in medication administration (>5 min time from event
The NRCPR database contains a section for the data abstractor recognition to first dose of a vasoconstrictor), defibrillation, air-
at each hospital site to capture  self-reported system errors that way management, and chest compression performance errors. The
were noted during or following the resuscitation effort on the code 5.4% of cases having a delay in defibrillation of >2 min repre-
record and/or hospital chart or to document errors reported by sents the percentage of patients with defibrillation delays using all
J.P. Ornato et al. / Resuscitation 83 (2012) 63 69 65
Table 1
Distribution of resuscitation system errors.
Error category N % of cases % of reported resuscitation system errors
Alerting
Delay in alerting code team 232 0.2
Pager issue 66 0.1
1.1
Other 266 0.2
Airway
Aspiration related to provision of airway 225 0.2
Airway insertion delay 2672 2.3
Delayed recognition of airway misplacement 328 0.3
17.0
Intubation attempted, not achieved 319 0.3
Multiple intubation attempts 3314 2.8
Other 1939 1.6
Vascular access
Delay in obtaining access 846 0.7
Inadvertent arterial cannulation 37 <0.1
3.4
Infiltration or inadvertent disconnection of IV line 415 0.4
Other 480 0.4
Chest compression
Compression rate of <"100/min not maintained 2530 2.1
Interruption of compressions >10 s at any time 177 0.1
Delay in starting chest compressions 155 0.1
7.2
No board used beneath patient during compressions 758 0.6
Other 120 0.1
Defibrillation
Defibrillation delay >2 min from event recognition in 6364 5.4
patients with an initial CA rhythm of VF/pVT due to
insufficient trained personnel or defibrillator not
immediately available
19.0
Energy level too high/low based on AHA guidelines 485 0.4
Incorrect defibrillator paddle/pad placement 32 <0.1
Defibrillator malfunction 131 0.1
Shock given, not indicated 957 0.8
Shock indicated, not given 607 0.5
Other 1068 0.9
Medications
First vasopressor (epinephrine or vasopressin) delay 20,035 16.9
>5 min from event recognition in cases with event
42.5
duration >5 min
Wrong route of administration 202 0.2
Wrong dosage 575 0.5
Wrong medication selection 1190 1.0
Code team leadership
Delay in identifying team leader 276 0.2
Knowledge of equipment 107 0.1
Knowledge of medications/protocols 539 0.5
2.8
Knowledge of team member roles 223 0.2
Code team oversight 196 0.2
Too many individuals present in room 105 0.1
Protocol deviation from AHA Guidelines
Deviation from AHA ACLS guideline recommendations 1521 1.3
3.1
Other 84 0.1
Equipment issues
Availability 1100 0.9
Malfunction 540 0.5
3.9
Other 387 0.3
patients as the denominator including those without initial shock- ICU/stepdown units (17,692/69,643, 25.8%), EDs (3491/12,830,
able rhythms. There were 6364 patients with defibrillation delays 27.2%), or Operating Room/Post-Anesthesia Care Units (685/2913,
of >2 min out of 20,125 patients with an initial shock-able rhythm 23.5%) (p = .0001).
documented, yielding a delay in defibrillation in 31.6% of patients The presence of documented resuscitation system errors on an
in whom defibrillation was indicated. IHCA event was associated with decreased rates of ROSC, survival
Table 2 displays the demographic characteristics of IHCA events to 24 h, and survival to hospital discharge (Fig. 1) in all patients as a
with and without reported resuscitation system errors. Cases in group and in those whose initial documented IHCA rhythm was
which system errors were documented were more likely to be male, separated into VF/pVT or non-VF/pVT categories. Characteristics
not witnessed/monitored at the time of arrest, during the night that increased the likelihood of death prior to hospital discharge
(11p 7a), on weekends (S Su), initially in VF/pVT, medical (vs. sur- in patients whose initial rhythm was non-VF/pVT included: male
gical or cardiac) type admissions, or non-ICU patients (vs. ICU, ED, gender, when the event occurred at night or on a weekend, or when
or OR/PACU patients) than cases in which no system errors were there were documented resuscitation system errors (Fig. 2). There
documented. was a lower likelihood of death prior to hospital discharge if the
Resuscitation system errors occurred in the highest percentage event was witnessed or monitored, if the type of patient was car-
of IHCA events in non-ICU inpatient areas (9838/24,378, 40.4%); diac or surgical (as opposed to general medical), and if the patient
they were least frequently noted on IHCA events occurring in location was OR/PACU.
66 J.P. Ornato et al. / Resuscitation 83 (2012) 63 69
Table 2
Demographic characteristics of in-hospital CA events with and without resuscitation system errors.
No resuscitation system errors Resuscitation system errors p
N (total = 118,387) 84,440 (71.3%) 33,947 (28.7%) 
Age [mean, 95% CI] 66.07 [65.96, 66.18] 66.36 [66.20, 66.53] .008
Male 48,428/84,440 (57.4%) 19,951/33,947 (58.8%) .0001
Witnessed or monitored arrest 69,361/70,152 (98.9%) 25,729/26,636 (96.6%) .0001
Initial documented CA rhythm VF/pVT 14,573/76,143 (19.1%) 9894/32,493 (30.4%) .0001
Patient type
Cardiac 29,329/81,750 (35.9%) 11,487/33,757 (34.0%)
Medical 34,777/81,750 (42.5%) 15,483/33,757 (45.9%)
.0001
Surgical 17,644/81,750 (21.6%) 6787/33,757 (20.1%)
CA event location
ICU or stepdown/telemetry area 50,951/77,057 (66.1%) 17,692/31,707 (55.8%)
Non-ICU inpatient area 14,539/77,057 (18.9%) 9838/31,707 (31.0%)
.0001
Emergency department 9339/77,057 (12.1%) 3491/31,707 (11.0%)
Operating room or PACU 2228/77,057 (2.9%) 685/31,707 (2.2%)
Time of day
Day-evening (7a 11p) 54,888/80,480 (68.2%) 22,387/33,777 (66.3%)
.0001
Night (11p 7a) 25,592/80,480 (31.8%) 11,390/33,777 (33.7%)
Day of week
Weekday (M F) 56,783/81,970 (69.3%) 23,236/10.711 (68.4%)
.003
Weekend (S Su) 25,187/81,970 (30.7%) 10,711/33,947 (31.6%)
Fig. 1. Effect of any resuscitation system errors on an IHCA event and the rate of ROSC, survival for 24 h, and survival to hospital discharge for all patients and those with an
initial documented IHCA rhythm of non-VF/pVT and VF/pVT.
Fig. 2. Association between the number of resuscitation system errors during an IHCA event and a significantly increased hazard ratio for death prior to hospital discharge
stratified by patients with an initial IHCA rhythm of non-VF/pVT or VF/pVT.
J.P. Ornato et al. / Resuscitation 83 (2012) 63 69 67
Characteristics that increased the likelihood of death prior to experience in performing resuscitation compared to clinicians
hospital discharge in patients whose initial rhythm was VF/pVT working on general hospital floors. Our paper supports this hypoth-
included: when the event occurred at night or on a weekend, or esis by confirming that IHCA events occurring in the ED have a
when there were documented resuscitation system errors (Fig. 2). relatively low percentage of cases with resuscitation system errors.
There was a lower likelihood of death prior to hospital discharge Not all types of errors were associated with an increased hazard
if the type of patient was cardiac or surgical (as opposed to gen- ratio for death prior to hospital discharge in our study. Olasveen-
eral medical) or if the patient location was ED. The relative risk of gen et al.,17 randomized out-of-hospital cardiac arrest patients to
death prior to hospital discharge based on hazard ratio analysis was receive ACLS treatment with and without intravenous drug admin-
9.9% (95% CI 7.8, 12.0) more likely for patients whose initial docu- istration and determined that survival to discharge was the same in
mented rhythm was non-VF/pVT when resuscitation system errors both groups. However, they were not able to identify the timeframe
were reported compared to when no errors were reported. It was in which the drug therapy was given in the group that received
34.2% (95% CI 29.5, 39.1) more likely for those with VF/pVT. an intravenous line and medication. In our IHCA population, we
Only certain types of resuscitation system errors were asso- were able to demonstrate decreased survival when the first vaso-
ciated with an increased hazard ratio for death prior to hospital constrictor was administered >5 min after IHCA onset in patients
discharge. For patients whose initial rhythm was non-VF/pVT, whose arrest lasted for at least 5 min. The difference in our find-
delays in obtaining vascular access (i.e., an intravenous line) and ings is likely due to the fact that the time from event onset to first
medication errors increased the hazard ratio for death prior to drug administration is usually much shorter in- vs. out-of-hospital.
hospital discharge (Fig. 3). For patients whose initial rhythm was In our study, the mean time from event onset to first epinephrine
VF/pVT, defibrillation problems and medication errors increased was 2.4 (95% CI, 2.3, 2.4) min. In contrast, the time interval from
the hazard ratio for death prior to hospital discharge. collapse to first epinephrine in standard vs. high dose epinephrine
pre-hospital trials is approximately 20 min.18
Much of the focus on patient safety and error prevention in hos-
4. Discussion pitals focuses on interventions that relate to patient interactions
that are of higher volume and lower acuity compared to resus-
The principal finding in this study is that the presence of resus- citation. In our study, the impact of resuscitation team errors on
citation system errors is associated with decreased survival from survival varied widely by both error type and the initial docu-
IHCA in adults. More errors were noted in patients whose initial mented heart rhythm, with some errors causing little or no impact
documented IHCA rhythm was VF/pVT as opposed to those with and others being associated with a significantly lower survival, par-
non-shock-able rhythms. This finding is particularly relevant clin- ticularly in the group of patients with initial VF/pVT. Given that
ically, given that the majority of survivors of IHCA are those with resuscitation practices need to occur consistently well throughout
initial VF/pVT.3 all areas of the hospital and that responders will always have vary-
Our findings, although much broader, support those reported ing degrees of expertise and experience, our findings suggest that
by Chan et al.4 who evaluated 6789 sequential patients with VF resuscitation training should be targeted to emphasize avoiding the
as the first documented rhythm in the NRCPR database and found types of errors having the greatest impact on survival (e.g., delays in
that 30.1% of this cohort underwent defibrillation more than 2 min initial defibrillation and medication administration and adherence
after initial recognition of their IHCA. Patients with delayed defib- to ACLS protocols).
rillation had a significantly lower likelihood of ROSC (adjusted odds An increasing body of evidence indicates that effective lead-
ratio, 0.55; 95% CI, 0.49 0.62; p < 0.001) and survival at 24 h after ership and team work rather than just individual knowledge,
the cardiac arrest (adjusted odds ratio, 0.52; 95% CI, 0.46 0.58; skills, and attitudes are required to optimize outcomes and min-
p < 0.001). The Chan study was the first large scale analysis of data imize errors in a variety of medical emergencies.8 15,16 Specific
in IHCA patients identifying a specific defibrillation delay time cut- behaviors have been identified that contribute to effective leader-
off (2 min or less after event recognition) that negatively impacts ship including providing orienting remarks, inviting team member
survival. Our analysis, in a larger sample size from the same reg- contributions, promoting exchange of information and clear com-
istry, confirms that defibrillation system errors, including a >2 min munication, and avoiding performing physical tasks that can be
delay from IHCA recognition to initial defibrillation accounts for assigned to others during the emergency.8 In addition, there are
higher mortality in the initial VF/pVT group, but it also found an four teamwork behavior principles that can help to avoid medi-
association between medication errors and a lower likelihood of cal errors: (1) the leader should voice specific findings rather than
survival. diagnosing the problem prematurely; (2) all members of the team
Peberdy et al.3 found that survival to discharge following in- should  think out loud and  talk to the room as the case unfolds;
hospital cardiac arrest is lower during nights (14.7% [95% CI, (3) the leader should direct period reviews of quantitative infor-
14.3 15.1%] vs. 19.8% [95% CI, 19.5 20.1%]) or weekends (20.6% mation (e.g., drug dose, time, response); and (4) all members of the
[95% CI, 20.3 21%] vs. 17.4% [95% CI, 16.8 18%]) compared with team should double-check crucial data.8
day/evening or weekdays, even after accounting for many poten- Unfortunately, the majority of these leadership and team behav-
tially confounding IHCA event and hospital factors. Our current iors could not be measured in this study. This is the likely
study confirms that nights and weekends are associated with an explanation for why we were unable to demonstrate an association
increased hazard ratio for death prior to hospital discharge in with reported  poor team leadership and survival in our study. The
patients regardless of the initial documented IHCA rhythm and goes definition of  good team leadership is subjective and may not be
a step beyond the previously reported data in demonstrating an reported consistently among institutions or that that magnitude of
increased hazard ratio for death during those times in which there the effect on survival of other resuscitation errors drowns out the
is an increase in resuscitation system errors, thus suggesting a link impact of poor team leadership.
between increased error on nights and weekends and decreased Our observations confirm the association between the presence
survival during those times. of resuscitation system errors that are evident from review of the
Kayser et al.,5 demonstrated that ED location was an inde- resuscitation record and decreased survival from IHCA in adults.
pendent predictor of improved survival, speculating that this was However, they do not point to a specific solution to the problem.
due to both the requirement for ED staff to receive basic and A number of recent simulator-based studies have identified
the advanced cardiac life support training, and their frequent qualitatively and quantitatively similar problems to those noted
68 J.P. Ornato et al. / Resuscitation 83 (2012) 63 69
Fig. 3. Association between various types of resuscitation system errors and the hazard ratio for death prior to hospital discharge in patients whose initial IHCA rhythm was
non-VF/pVT and VF/pVT.
during clinical resuscitation.4,19 24 Team training can improve per- findings. Finally, we cannot exclude the possibility that individu-
formance during simulation of medical emergencies,25 28 but not als completing the code sheets could have checked off more  error
all training is equal or effective.12 14 Siassakos et al.,12 14 have iden- boxes in patients who did not achieve ROSC than the boxes they
tified specific elements required to improve outcome, including would have checked had the patient been resuscitated.
multi-professional training of all healthcare providers who man-
age an emergency in a realistic simulation setting. These elements 4.2. Public health importance
need to be incorporated into team and leadership training, which
are now recommended in the 2010 American Heart Association The public health importance of these findings is con-
Guidelines for Adult and Pediatric Advanced Cardiovascular Life siderable. Eisenberg and Mengert,31 estimated that there are
Support.29,30 350,000 750,000 adult, IHCA events per year in the United States.
Eliminating resuscitation system errors has the potential to save
21,000 44,000 additional lives per year in the United States from
4.1. Limitations
IHCA. This figure is ten times larger than the estimated 2000 4000
additional lives saved per year from out-of-hospital cardiac arrest
General limitations of NRCPR include: (1) registry hospitals may
that drove widespread deployment of public access defibrillation
not be representative of all hospitals; (2) there is no on-site valida-
programs throughout the country.13
tion of data collection; (3) and there is no follow-up after hospital
discharge. In addition, although medication use is tracked, NRCPR
5. Conclusions
does not attempt to assess clinical eligibility for each medication.
These limitations are similar to those of other contemporary in-
We conclude that the presence of resuscitation system errors
hospital registries.
that are evident from review of the resuscitation record is associ-
The specific limitation pertinent to this analysis is that NRCPR
ated with decreased survival from IHCA in adults. Hospitals should
data is self-reported by having a trained abstractor review hospi-
target their training of first responders and code team personnel
tal charts and code records. The Get with the Guidelines NRCPR is
to emphasize the importance of early defibrillation when indi-
a voluntary data collection/analysis quality improvement project.
cated, early use of vasoconstrictor medication, and compliance with
Participating hospitals pay a fee to the American Heart Associa-
established AHA ACLS resuscitation protocols.
tion to have the data analyzed, benchmarked, and reported back
to them quarterly. With hundreds of hospitals involved through-
Conflict of interest statement
out the entire United States and very minimal hospital user fees, it
has not been feasible to provide independent data validation at the
None of the authors have any relevant conflicts.
hospital level.
The abstractors work with uniform definitions and uniform
Funding sources
methods of data acquisition. The abstractors review the physi-
cian and nurse narrative notes in the hospital chart and the  code
None.
record on each event. Thus, all of the errors identified came from a
review of documentation in the patient charts. The abstractors do
Acknowledgement
not capture whether the errors were  recognized in the narrative
notes by the doctors and nurses running the code or are evident
None.
from the documentation of events themselves (which is the case
for the majority of errors that we looked at).
There is no way for the abstractor to verify whether errors may Appendix A.
have occurred but were not documented. This may have resulted
in an under-reporting of resuscitation team errors. If this occurred, Get with the Guidelines  National Registry of Cardiopulmonary
if anything, it would increase the potential importance of our Resuscitation (NRCPR) investigators:
J.P. Ornato et al. / Resuscitation 83 (2012) 63 69 69
Mary E. Mancini, Robert A. Berg, Emilie Allen, Elizabeth A. Hunt, 16. Manser T. Teamwork and patient safety in dynamic domains of health-
care: a review of the literature. Acta Anaesthesiol Scand 2009;53:
Vinay M. Nadkarni, Scott Braithwaite, Graham Nichol, Kathy Dun-
143 51.
can, Tanya Lane Truitt, Melinda Smyth, Brian Eigel, Paul S. Chan,
17. Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L. Intravenous
Tim Mader, Karl B. Kern, Sam Warren, Thomas Noel, Romergryko drug administration during out-of-hospital cardiac arrest: a randomized trial.
JAMA 2009;302:2222 9.
Geocadin, Dana Edelson, Vince Mosesso and Comilla Sasson.
18. Brown CG, Martin DR, Pepe PE, et al. A comparison of standard-dose and high-
dose epinephrine in cardiac arrest outside the hospital. The Multicenter High-
Dose Epinephrine Study Group. N Engl J Med 1992;327:1051 5.
References
19. Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resusci-
tation during in-hospital cardiac arrest. JAMA 2005;293:305 10.
1. Institute of Medicine. To err is human: building a safer health system. Washing- 20. Abella BS, Sandbo N, Vassilatos P, et al. Chest compression rates during
ton, DC: National Academy Press; 2000. cardiopulmonary resuscitation are suboptimal: a prospective study during in-
2. University study identifies problems with IOM report. Hosp Case Manag hospital cardiac arrest. Circulation 2005;111:428 34.
2000;8(Suppl. 3 4):146. 21. Kramer-Johansen J, Myklebust H, Wik L, et al. Quality of out-of-hospital car-
3. Peberdy MA, Ornato JP, Larkin GL, et al. Survival from in-hospital cardiac arrest diopulmonary resuscitation with real time automated feedback: a prospective
during nights and weekends. JAMA 2008;299:785 92. interventional study. Resuscitation 2006;71:283 92.
4. Chan PS, Krumholz HM, Nichol G, Nallamothu BK. Delayed time to defibrillation 22. Chan PS, Nichol G, Krumholz HM, Spertus JA, Nallamothu BK. Hospital varia-
after in-hospital cardiac arrest. N Engl J Med 2008;358:9 17. tion in time to defibrillation after in-hospital cardiac arrest. Arch Intern Med
5. Kayser RG, Ornato JP, Peberdy MA. Cardiac arrest in the emergency depart- 2009;169:1265 73.
ment: a report from the National Registry of Cardiopulmonary Resuscitation. 23. Hunziker S, Tschan F, Semmer NK, Howell MD, Marsch S. Human factors in
Resuscitation 2008;78:151 60. resuscitation: lessons learned from simulator studies. J Emerg Trauma Shock
6. Nadkarni VM, Larkin GL, Peberdy MA, et al. First documented rhythm and clin- 2010;3:389 94.
ical outcome from in-hospital cardiac arrest among children and adults. JAMA 24. Hunziker S, Tschan F, Semmer NK, et al. Hands-on time during cardiopulmonary
2006;295:50 7. resuscitation is affected by the process of teambuilding: a prospective ran-
7. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults domised simulator-based trial. BMC Emerg Med 2009;9:3.
in the hospital: a report of 14720 cardiac arrests from the National Registry of 25. Thomas EJ, Taggart B, Crandell S, et al. Teaching teamwork during the
Cardiopulmonary Resuscitation. Resuscitation 2003;58:297 308. Neonatal Resuscitation Program: a randomized trial. J Perinatol 2007;27:
8. Hunziker S, Johansson AC, Tschan F, et al. Teamwork and leadership in cardiopul- 409 14.
monary resuscitation. J Am Coll Cardiol 2011;57:2381 8. 26. Thomas EJ, Williams AL, Reichman EF, Lasky RE, Crandell S, Taggart WR. Team
9. Schaefer HG, Helmreich RL. The importance of human factors in the operating training in the neonatal resuscitation program for interns: teamwork and quality
room. Anesthesiology 1994;80:479. of resuscitations. Pediatrics 2010;125:539 46.
10. Schaefer HG, Helmreich RL, Scheidegger D. Human factors and safety in emer- 27. Cooper S. Developing leaders for advanced life support: evaluation of a training
gency medicine. Resuscitation 1994;28:221 5. programme. Resuscitation 2001;49:33 8.
11. Schaefer HG, Helmreich RL, Scheidegger D. Safety in the operating theatre  28. Hunziker S, Buhlmann C, Tschan F, et al. Brief leadership instructions improve
part 1: interpersonal relationships and team performance. Curr Anaesth Crit cardiopulmonary resuscitation in a high-fidelity simulation: a randomized con-
Care 1995;6:48 53. trolled trial. Crit Care Med 2010;38:1086 91.
12. Siassakos D, Bristowe K, Draycott TJ, et al. Clinical efficiency in a simulated emer- 29. Bhanji F, Mancini ME, Sinz E, et al. Part 16: education, implementation,
gency and relationship to team behaviours: a multisite cross-sectional study. and teams: 2010 American Heart Association Guidelines for Cardiopul-
BJOG 2011;118:596 607. monary Resuscitation and Emergency Cardiovascular Care. Circulation
13. Siassakos D, Draycott TJ, Crofts JF, Hunt LP, Winter C, Fox R. More to teamwork 2010;122:S920 33.
than knowledge, skill and attitude. BJOG 2010;117:1262 9. 30. Mancini ME, Soar J, Bhanji F, et al. Part 12: education, implementation, and
14. Siassakos D, Fox R, Crofts JF, Hunt LP, Winter C, Draycott TJ. The management teams: 2010 International Consensus on Cardiopulmonary Resuscitation and
of a simulated emergency: better teamwork, better performance. Resuscitation Emergency Cardiovascular Care Science with Treatment Recommendations. Cir-
2011;82:203 6. culation 2010;122:S539 81.
15. Tourgeman-Bashkin O, Shinar D, Zmora E. Causes of near misses in critical care 31. Eisenberg MS, Mengert TJ. Cardiac resuscitation. N Engl J Med
of neonates and children. Acta Paediatr 2008;97:299 303. 2001;344:1304 13.