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Errors During Resuscitation: The Impact of Perceived Authority on Delivery of Care

Delaloye Nicole Jane BA BSc; Tobler, Kathy MD, FRCPC; O'Neill, Thomas BA, PhD; Kotsakis, Afrothite MD, FRCPC; Cooper, Jessica BSc, Hons; Bank, Ilana MD, FRCPC; Gilfoyle, Elaine MD, MMEd, FRCPC; On behalf of The Teams4Kids Investigators and the Canadian Critical Care Trials Group
Journal of Patient Safety: Post Author Corrections: June 30, 2017
doi: 10.1097/PTS.0000000000000359
Original Article: PDF Only


The aim of this study was to determine the influence of perceived authority on pediatric resuscitation teams' response to an incorrect order given by a medical superior.


As part of a larger multicenter prospective interventional study, interprofessional pediatric resuscitation teams (n = 48) participated in a video-recorded simulated resuscitation scenario with an infant in unstable, refractory supraventricular tachycardia. A confederate actor playing a senior physician entered the scenario partway through and ordered the incorrect dose and delivery method of the antiarrhythmic, procainamide. Video recordings were analyzed with a modified Advocacy Inquiry Scale, assessing the teams' ability to challenge the incorrect order, and a novel confederate hierarchical demeanor rating. The association between Advocacy Inquiry score and hierarchical demeanor rating, and whether or not the confederate's incorrect order was followed were determined.


Fifty percent (n = 24) of resuscitation teams followed the confederate's incorrect order. The teams' ability to challenge the incorrect order (P < 0.0001) and confederate hierarchical demeanor rating (P < 0.05) were significantly associated with whether or not the incorrect order was followed. Significant differences between rates of following the incorrect order at different study sites were observed (P < 0.05).


The reluctance of resuscitation teams to appropriately challenge the incorrect order resulted in a high rate of inappropriate medication administration. The rate of teams following the incorrect order was significantly associated with poor challenging of the incorrect order and the hierarchical demeanor of the perceived authority figure. Institution-based factors may impact this rate of incorrect medication administration.

Correspondence: Nicole J. Delaloye, BA, BSc, Alberta Children's Hospital, 2888 Shaganappi Trail NW, T3B 6A8 Calgary, Alberta, Canada (e-mail:

This study was jointly funded by the Heart and Stroke Foundation of Canada and the Canadian Institutes for Health Research.

The authors disclose no conflict of interest.

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