Cases & Commentaries

Resuscitation Errors: A Shocking Problem

Spotlight Case
Commentary By Benjamin S. Abella, MD, MPhil; Dana P. Edelson, MD

Case Objectives

  • Appreciate that delays in defibrillation
    can have significant negative effects on survival from cardiac
    arrest.
  • List the most common causes of
    defibrillator failures.
  • Appreciate the importance of hands-on,
    ongoing training on defibrillator devices for users.
  • Propose the use of checklists by
    rescuers at their institution to assess the readiness of the
    defibrillator and its components.

Case & Commentary: Part 1

A middle-aged man presented to the hospital
with chest pain. He was stabilized in the emergency department and
admitted to the telemetry ward. He later developed torsades de
pointes (an unusual form of ventricular tachycardia that can be
fatal if untreated) while on telemetry, associated with loss of his
pulse. A code blue was called. The cardiology resident arrived and
confirmed torsades on the monitor. Defibrillation pads were placed
on the patient, but when the nurse tried to connect the pads to the
defibrillation unit, the cables did not connect. In the ensuing
confusion, it soon became apparent that the pads and the box were
not compatible.

Sudden cardiac arrest (SCA) is a leading cause of
death worldwide, claiming more than 300,000 lives each year in the
United States alone.(1) SCA
presents a difficult clinical problem, as it often occurs with
little warning and requires a complex set of resuscitative actions
to be instituted within minutes. It is perhaps not surprising,
therefore, that survival from cardiac arrest is poor, with
out-of-hospital SCA survival to discharge generally reported at
less than 10%, and survival from in-hospital SCA estimated at 18%
from one large national registry.(2-4)

Provided that an electrical shock is applied to
the chest quickly, SCA associated with ventricular fibrillation
(VF) or ventricular tachycardia (VT) has the best chance of
survival. Studies have consistently shown that survival from VF
decreases profoundly over the course of minutes in the absence of
defibrillation (Figure).(5)
Although the provision of cardiopulmonary resuscitation (CPR)
ameliorates this effect, this protection wanes quickly.
Defibrillation failure rates increase within seconds when CPR is
suspended preceding defibrillation.(6)

CPR and electrical defibrillation serve as the
essential treatment options for SCA. These therapies are taught to
most health care providers, yet performance of these surprisingly
complex skills has only recently been objectively measured during
actual SCA events and was found to be poor.(7-9) Specifically, CPR parameters are often non-compliant
with American Heart Association resuscitation guidelines. Common
errors include slow chest compression rates, shallow chest
compression depths, hyperventilation, long pauses in CPR before
shock delivery, and delivery of electrical defibrillation for
non-shockable rhythms. Likely reasons for the variable quality of
resuscitation care are infrequent practice of resuscitation skills
training by hospital staff and the need for providers to
immediately function as a team with others with whom they have not
rehearsed.

Unfortunately, defibrillator user errors, such as
the one described in this scenario, are not uncommon. In the late
1980s, the Defibrillator Working Group of the U.S. Food and Drug
Administration (FDA) reviewed data from the FDA's Medical Device
Reporting System (including 1327 reports of defibrillator failures)
and from a large number of defibrillator inspections and site
visits. They concluded that user errors accounted for most failures
and resulted in important defibrillation time delays.(10)
Common user errors included holding the defibrillator in a charged
state too long (such that the device discharges automatically and
requires recharging for actual use), attempting to shock VF in
synchronized mode, and inattention to lead selection. These errors
have been described in scholarly reviews as well.(11) Additionally, failure to properly maintain and check
devices, such that batteries were not properly charged and devices
were kept in circulation far in excess of their natural life
expectancy of 5–8 years, led to further errors.(10,12)
Finally, mismatch of cables with specific defibrillators was
described in another published report.(13) Unfortunately, it is often the case that these errors
are only noted during an emergency situation, once cardiac arrest
has occurred, such that an equipment problem that might have been
easily remedied before an event can suddenly present a major hazard
to patient survival.

Case & Commentary: Part 2

The patient remained in torsades until the
resident administered magnesium, which resulted in rapid conversion
to sinus rhythm. The patient was ultimately stabilized and
transferred to the cardiac intensive care unit. He suffered no
long-term ill effects.

To reduce avoidable errors, as occurred in this
case, the Defibrillator Working Group recommended use of a
checklist (see Table) by the clinical operators as well as
adherence to a maintenance schedule for both the device itself and
accompanying batteries. Additionally, they recommended that all
defibrillator users receive training in the specific device(s) they
are going to use and continued hands-on experience with the device
(in cardiac arrests or training) at least every 3 months to
maintain those skills. The recommendation for checklists has been
echoed by other experts and has been incorporated into the Advanced
Cardiac Life Support (ACLS) guidelines.(14-16)

The Defibrillator Working Group found fewer
errors in high-use locations such as emergency departments and
critical care units, consistent with the notion that increased
experience and frequency of device use result in better familiarity
and reduced user error.(10)
The availability of different defibrillator models in a given
hospital has been shown in simulated situations to result in device
confusion and increased time to defibrillation.(17) Uniformity of the make and model of defibrillators
has been recommended to address these potential problems.(18)

A variety of methods have been proposed to
improve resuscitation care, including increasing the frequency of
resuscitation skills training and introducing mock SCA events into
clinical care routines. Leadership and group training exercises may
help improve team function. Routine incorporation of SCA event
debriefing can identify common errors and exploit "teachable
moments" for further skills improvement. With regard to equipment
usage and supply errors such as those described in this case,
whenever possible, equipment should be standardized across an
institution or health service provider. This is particularly
difficult in larger institutions with many distinct cost centers
purchasing defibrillators at varying times. In this case,
institutional recommendations for devices should be made widely
accessible by resuscitation leadership, such as the hospital CPR or
"code" committee, so that uniformity can be maintained when an
individual clinical unit seeks to replace outdated equipment. All
potential rescuers should receive hands-on, device-specific
training, with refreshers every 3 months for those in low-use
clinical areas.

With regard to equipment problems such as those
described by the case in question, a daily (or per shift for
high-use areas) equipment checklist should be completed by a member
of the resuscitation team or assigned nurse located on a given unit
or ward. Specifically, a checklist should be used that ensures that
there is no damage to the device, that all components match the
device and attach correctly, that the defibrillator battery is
charged, and that the device is plugged into wall power for
recharging (see Table). Since performing this checklist is a way of
familiarizing oneself with the device, as many of the potential
rescuers as is reasonable should be taught to perform these
inspections and rotate in that responsibility. Biomedical
technicians or engineers should perform additional checks every 6
months or as recommended by the manufacturer.

Case & Commentary: Part 3

This incident prompted a major review of code
blue procedures, an inventory of the types of defibrillator
machines and pads, and an effort to crosscheck machine–pad
compatibility. The review resulted in the machines and pads being
standardized at this particular hospital, in an effort to eliminate
the possibility of this error in the future.

The case detailed here illustrates an
all-too-common user error that ultimately reflects a larger systems
error. It resulted from having multiple devices in one institution
and from failing to use a thorough checklist procedure. Such
checklists are a proven tool in such industries as aviation, where
a highly complex set of equipment must function correctly with
essentially zero tolerance for error. However, it must be
emphasized that instituting a checklist is necessary but not
sufficient—as in aviation, staff must be educated as to the
crucial need to strictly follow checklist procedures and must be
motivated to embrace a culture of safety that incorporates such
tools. CPR committees at hospitals can serve as crucial champions
in this systems approach and should advocate strongly for
uniformity of devices and equipment as well as for routine device
education and assessment. In this important process, CPR committee
members and physician champions for resuscitation care should
partner with nurse educators through the hospital system to achieve
these objectives. Through such advocacy, resuscitation equipment
can become both familiar and safe, and cardiac arrest care can be
approached with greater confidence by all members of the hospital
team.

Take-Home Points

  • Delays in defibrillation can have
    significant negative effects on survival from cardiac arrest.
  • Although most failures to defibrillate
    are due to user error, they occur in the context of systems
    problems caused by device confusion and failure to properly
    maintain defibrillators and their disposable supplies.
  • When possible, defibrillators should be
    standardized within institutions.
  • Rescuers should be trained on the device
    they are going to use and should have frequent hands-on experience
    with the defibrillator, either in clinical practice or
    simulations.
  • Rescuers should use checklists to assess
    the readiness of the defibrillator and its components on a daily
    basis.

Benjamin S. Abella, MD, MPhil
Assistant Professor, Department of Emergency Medicine
University of Pennsylvania

Dana P. Edelson, MD
Instructor, Section of General Internal Medicine
University of Chicago

Faculty Disclosure: Dr. Abella has
received research funding from the NIH, Philips Medical Systems,
and Cardiac Science Corporation. He reported a consultant
relationship with and speaking honoraria from Philips Medical
Systems and speaking honoraria from Zoll Medical Corporation. Dr.
Edelson has received research funding and speaking honoraria from
Philips Medical Systems and speaking honoraria from Zoll Medical
Corporation. The commentary does not include information regarding
investigational or off-label use of products or devices. All
conflicts of interest have been resolved in accordance with the
ACCME Updated Standards for commercial support.

References

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3. Lombardi G, Gallagher J, Gennis P. Outcome of
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4. Peberdy MA, Kaye W, Ornato JP, et al.
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5. Wik L, Hansen TB, Fylling F, et al. Delaying
defibrillation to give basic cardiopulmonary resuscitation to
patients with out-of-hospital ventricular fibrillation: a
randomized trial. JAMA. 2003;289:1389-1395.
[go to PubMed]

6. Edelson DP, Abella BS, Kramer-Johansen J, et
al. Effects of compression depth and pre-shock pauses predict
defibrillation failure during cardiac arrest. Resuscitation.
2006;71:137-145.
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8. Abella BS, Alvarado JP, Myklebust H, et al.
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arrest. JAMA. 2005;293:305-310.
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9. Abella BS, Sandbo N, Vassilatos P, et al.
Chest compression rates during cardiopulmonary resuscitation are
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problems and recommendations for improvement. JAMA.
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12. Emergency Care Research Institute. Hazard:
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13. Emergency Care Research Institute. Hazard:
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Table

Table. Defibrillator Checklist

Inspection Items OK as Found Corrective Action/Notes
1. Defibrillator
   a. Clean
   b. Nothing on top
   c. No damage
2. Cables/connectors
   a. Match the device
   b. Engage securely
   c. No damage
3. External paddles (including pediatric adapters)*
   a. Clean, not pitted
   b. Release from housing easily
4. Internal paddles*
   a. Match the device
   b. Sterile
5. Pads*
   a. 2 sets
   b. Match the device
   c. Within expiration date
6. Supplies (verify presence and condition of)
   a. Electrodes
   b. Razor
   c. Spare ECG paper
   d. Spare battery
   e. Gel
7. Indicators/ECG Display
   a. Power "on"
   b. Self test ok
   c. Monitor display functional
   d. "service" message display off
   e. "Battery charging" light on, "low battery"
light off
   f. Time correct, synchronized with other clocks
if possible
8. ECG recorder
   a. Adequate paper
9. Power supply
   a. AC/DC cord plugged in
   b. Spare battery charging
   c. Rotate batteries per manufacturer
recommendations
10. Defibrillation ability
   a. Charge and discharge per manufacturer
recommendations
   
Signature_________________________ Date______ Time______

*If applicable.

Adapted with permission from Elsevier.
(Originally published in: White RD. Maintenance of defibrillators
in a state of readiness. Ann Emerg Med. 1993;22:302-306.)

Figure

Figure. Survival as a Function of Time to
Shock.


Survival from sudden cardiac arrest due to
ventricular fibrillation as a function of time from emergency
notification to first shock. Adapted with permission from JAMA.
Copyright © 2003, American Medical Association. All rights
reserved. (Wik L, Hansen TB, Fylling F, et al. Delaying
defibrillation to give basic cardiopulmonary resuscitation to
patients with out-of-hospital ventricular fibrillation: a
randomized trial. JAMA. 2003;289:1389-1395.)