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Critical incidents during prehospital cardiopulmonary resuscitation: what are the problems nobody wants to talk about?

Hohenstein, Christian; Rupp, Peter; Fleischmann, Thomas

European Journal of Emergency Medicine: February 2011 - Volume 18 - Issue 1 - p 38–40
doi: 10.1097/MEJ.0b013e32833b1a61

We wanted to identify incidents that led or could have led to patient harm during prehospital cardiopulmonary resuscitation. A nationwide anonymous and Internet-based critical incident reporting system gave the data. During a 4-year period we received 548 reports of which 74 occurred during cardiopulmonary resuscitation. Human error was responsible for 85% of the incidents, whereas equipment failure contributed to 15% of the reports. Equipment failure was considered to be preventable in 61% of all the cases, whereas incidents because of human error could have been prevented in almost all the cases. In most cases, prevention can be accomplished by simple strategies with the Poka-Yoke technique. Insufficient training of emergency medical service physicians in Germany requires special attention. The critical incident reports raise concerns regarding the level of expertize provided by emergency medical service doctors.

Department of Emergency Medicine, University Hospital Jena, Erlanger Allee, Jena, Germany

Correspondence to Dr Christian Hohenstein, MD, Department of Emergency Medicine, University Hospital Jena, Erlanger Allee 101, 07740 Jena, Germany Tel: +49 170 2839929; fax: +49 3641 9322022; e-mail:

Received November 23, 2009

Accepted April 19, 2010

© 2011 Lippincott Williams & Wilkins, Inc.