Table 4

Characteristics of cardiopulmonary arrest events deemed “potentially avoidable”

Case number	Primary service	Length of hospital stay(days)*	Location of arrest		Event survival	Survival to discharge	Reason for avoidability	Pertinent history
Case number	Primary service	Length of hospital stay(days)*	Setting	Monitored	Event survival	Survival to discharge	Reason for avoidability	Pertinent history
AICD, automatic implantable cardioverter defibrillator; BiPAP, bi-level positive airway pressure; CABG, coronary artery bypass grafting; CHF, congestive heart failure; DVT, deep vein thrombosis; ICU, intensive care unit; IVC, inferior vena cava; MET, medical emergency team; MI, myocardial infarction; PE, pulmonary embolus; PEA, pulseless electrical activity; RRS, rapid response system.
(I) Failure to implement established guideline/policy = 8; (II) inadequate monitoring/surveillance = 5; (III) dithers/delays = 4; (IV) procedure/surgical complication = 3.
*Admission to arrest.
1	Neurosurgery	4	ICU	Yes	No	No	Failure to follow brain death protocol (I)	Subarachnoid haemorrhage; ventricular fibrillation during brain death protocol
2	Cardiology	3	ICU	Yes	Yes	No	Delay in MET/RRS activation (III)	MI, cardiogenic shock; third degree heart block, asystole
3	Transplant surgery	2	ICU	Yes	Yes	No	Failure to reset AICD postoperatively (I)	Kidney transplant; postoperative day 2—ventricular tachycardia, AICD did not fire
4	Medicine	0	Procedure unit	Yes	Yes	Yes	Procedure complication (IV)	Duodenal polyps; arterial bleed; PEA
5	Medicine	3	Inpatient unit	Yes	No	No	Failure to keep patient in bed (I)	Cocaine misuse, CABG; alarm for bradycardia in bathroom
6	Cardiothoracic surgery	4	Inpatient unit	Yes	Yes	No	Surgical complication (IV)	CABG (×4); bleeding from arterial bypass
7	Medicine	5	Procedure unit	Yes	Yes	Yes	Procedure complication (IV)	Tachycardia-bradycardia syndrome; asystole during IVC filter insertion
8	Cardiothoracic surgery	6	Inpatient unit	Yes	Yes	Yes	Delayed tracheostomy (I)	Failed extubation (×2); emesis, aspiration, asystole
9	Cardiothoracic surgery	0	Inpatient unit	Yes	No	No	Delay in cardiopulmonary intervention (III)	Acute MI; transferred for CABG, PEA arrest 19 h later
10	Cardiothoracic surgery	71	Inpatient unit	Yes	Yes	No	Delay in MET/RRS activation; delay in ICU transfer (III)	Empyema; respiratory failure, delay in ICU transfer
11	Cardiology	6	Inpatient unit	Yes	No	No	Delay in MET/RRS activation; delay in ICU transfer (III)	CHF, cardiogenic shock, dobutamine drip started outside ICU; PEA
12	Neurosurgery	7	Inpatient unit	Yes	Yes	Yes	Mismatch of resources to illness severity (II)	Odontoid fracture, quadriparesis; aspiration, apnoea
13	Cardiothoracic surgery	8	Inpatient unit	Yes	Yes	Yes	Very sick inpatient had study in “outpatient” setting (I)	Obstructive sleep apnoea, lung cancer resection; ventricular tachycardia
14	Gastroenterology	5	Inpatient unit	No	No	No	Mismatch of resources to illness severity (II)	Aortic stenosis; chest pain, altered mental status, fever, arrest during prolonged evaluation by trainee
15	Geriatric medicine	5	Inpatient unit	No	Yes	No	Mismatch of resources to illness severity (II)	Aspiration pneumonia; hypoxaemia, emesis, aspiration, asystole.
16	Neurosurgery	2	Inpatient unit	No	No	No	Patient not on DVT/PE protocol (I)	Spinal stenosis; postoperative day 2—PEA, pulmonary emboli
17	Medicine	1	Inpatient unit	No	Yes	No	Inadequate monitoring; failure to continue BiPAP (I, II)	Myasthenia gravis, Ogilvie syndrome; BiPAP prescribed, removed to go to bathroom; asystole
18	Medicine	4	Inpatient unit	No	No	No	Mismatch of resources to illness severity (II)	Found pulseless and apnoeic in bed in the morning, 13 days after aortic valve replacement
19	Critical care medicine	7	Inpatient unit	No	Yes	No	No DVT/PE prophylaxis in the last 2–3 days (I)	Non-ketotic hyperosmolar coma; pulmonary emboli, PEA