Ten years of incident reports on in-hospital cardiac arrest - Are they useful for improvements?

十年来的院内心脏骤停事件报告——它们对改进措施有用吗?

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Abstract

OBJECTIVES: Staff in hospitals are encouraged to write up incident reports whenever they notice an incident. There are few published compilations of these reports from an in-hospital cardiac arrest (IHCA) perspective. AIM: To describe content of incident reports over ten years in a two-sited university hospital in order to share knowledge and thereby being able to improve resuscitation systems in hospitals. MATERIAL AND METHODS: All incident reports between 2010-June 2023 written at Karolinska University Hospital contain the words "CPR", "cardiac arrest", "resuscitation", Do-Not-attend-CPR" (DNACPR), "life-sustaining treatment" were included for analysis. Reports were grouped into larger themes. RESULTS: In all 588 reports was identified automatically by the hospitals system based on the totally selected keywords. The largest category was "Life-sustaining treatment" with 178 (30%) reports and thereafter "Preventing care" (117, 20%) and "Material" (80, 14%). CONCLUSION: Our hospital has clearly valued incident reports as a mean to track on-going issues and serious events over time as well as a source to trigger educational interventions. To improve patient safety, a standardized approach for compilation of reports and actions would be helpful when sharing knowledge between hospitals and with the resuscitation community.

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