title: Impact of resuscitation system errors on survival from in-hospital cardiac arrest.
abstract: BACKGROUND
  An estimated 350,000-750,000 adult, in-hospital cardiac arrest (IHCA) events occur annually in the United States. The impact of resuscitation system errors on survival during IHCA resuscitation has not been evaluated. The purpose of this paper was to evaluate the impact of resuscitation system errors on survival to hospital discharge after IHCA.
  
  
  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 database from January 1, 2000 through August 26, 2008. Cox regression analysis was used to determine the relationship between reported resuscitation system errors and other important clinical variables and the hazard ratio for death prior to hospital discharge. Of the 108,636 patients whose initial IHCA rhythm was recorded, resuscitation system errors were committed in 9,894/24,467 (40.4%) of those with an initial 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 administration (>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 circulation, survival to 24h, 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 initial 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.
authors.affiliation: Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA 23298-0401, USA. ornato@aol.com
authors.forename: Joseph P
authors.initials: JP
authors.lastname: Ornato
authors.forename: Mary Ann
authors.initials: MA
authors.lastname: Peberdy
authors.forename: Renee D
authors.initials: RD
authors.lastname: Reid
authors.forename: V Ramana
authors.initials: VR
authors.lastname: Feeser
authors.forename: Harinder S
authors.initials: HS
authors.lastname: Dhindsa
mesh_terms: D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006323:Heart Arrest / Q000401:mortality* / Q000628:therapy; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D016016:Proportional Hazards Models; D012042:Registries; D012151:Resuscitation / Q000401:mortality*; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D014481:United States / Q000453:epidemiology