Table 4

 Characteristics of cardiopulmonary arrest events deemed “potentially avoidable”

Case numberPrimary serviceLength of hospital stay(days)*Location of arrestEvent survivalSurvival to dischargeReason for avoidabilityPertinent 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.
1Neurosurgery4ICUYesNoNoFailure to follow brain death protocol (I)Subarachnoid haemorrhage; ventricular fibrillation during brain death protocol
2Cardiology3ICUYesYesNoDelay in MET/RRS activation (III)MI, cardiogenic shock; third degree heart block, asystole
3Transplant surgery2ICUYesYesNoFailure to reset AICD postoperatively (I)Kidney transplant; postoperative day 2—ventricular tachycardia, AICD did not fire
4Medicine0Procedure unitYesYesYesProcedure complication (IV)Duodenal polyps; arterial bleed; PEA
5Medicine3Inpatient unitYesNoNoFailure to keep patient in bed (I)Cocaine misuse, CABG; alarm for bradycardia in bathroom
6Cardiothoracic surgery4Inpatient unitYesYesNoSurgical complication (IV)CABG (×4); bleeding from arterial bypass
7Medicine5Procedure unitYesYesYesProcedure complication (IV)Tachycardia-bradycardia syndrome; asystole during IVC filter insertion
8Cardiothoracic surgery6Inpatient unitYesYesYesDelayed tracheostomy (I)Failed extubation (×2); emesis, aspiration, asystole
9Cardiothoracic surgery0Inpatient unitYesNoNoDelay in cardiopulmonary intervention (III)Acute MI; transferred for CABG, PEA arrest 19 h later
10Cardiothoracic surgery71Inpatient unitYesYesNoDelay in MET/RRS activation; delay in ICU transfer (III)Empyema; respiratory failure, delay in ICU transfer
11Cardiology6Inpatient unitYesNoNoDelay in MET/RRS activation; delay in ICU transfer (III)CHF, cardiogenic shock, dobutamine drip started outside ICU; PEA
12Neurosurgery7Inpatient unitYesYesYesMismatch of resources to illness severity (II)Odontoid fracture, quadriparesis; aspiration, apnoea
13Cardiothoracic surgery8Inpatient unitYesYesYesVery sick inpatient had study in “outpatient” setting (I)Obstructive sleep apnoea, lung cancer resection; ventricular tachycardia
14Gastroenterology5Inpatient unitNoNoNoMismatch of resources to illness severity (II)Aortic stenosis; chest pain, altered mental status, fever, arrest during prolonged evaluation by trainee
15Geriatric medicine5Inpatient unitNoYesNoMismatch of resources to illness severity (II)Aspiration pneumonia; hypoxaemia, emesis, aspiration, asystole.
16Neurosurgery2Inpatient unitNoNoNoPatient not on DVT/PE protocol (I)Spinal stenosis; postoperative day 2—PEA, pulmonary emboli
17Medicine1Inpatient unitNoYesNoInadequate monitoring; failure to continue BiPAP (I, II)Myasthenia gravis, Ogilvie syndrome; BiPAP prescribed, removed to go to bathroom; asystole
18Medicine4Inpatient unitNoNoNoMismatch of resources to illness severity (II)Found pulseless and apnoeic in bed in the morning, 13 days after aortic valve replacement
19Critical care medicine7Inpatient unitNoYesNoNo DVT/PE prophylaxis in the last 2–3 days (I)Non-ketotic hyperosmolar coma; pulmonary emboli, PEA