Table 3.

Types of Errors Discussed During Weekly In‐Hospital Cardiac Arrest Debriefings

Type of Error	Examples
Delays in care	Delay in defibrillation (goal of ≤180 s)Delay in delivery of first dose of epinephrine for non‐shockable rhythm (goal of <5 min)Delay in starting chest compressions (breeched institutional goal of starting chest compressions in ≤10 s of loss of pulse or heart rate <60 with poor perfusion)
Pauses	Prolonged pause in chest compressions for the use of point‐of‐care ultrasoundProlonged pause during procedures (rhythm check, defibrillation, intubation, chest tube, surgical dissection for placement of ECMO catheters, etc.)Inadequate pause when unable to move chest with BMV and unable to intubate without pausingInadequate pause to assess initial rhythm and determine if defibrillation is indicated
Other	Defibrillating a non‐shockable rhythmUse of sodium bicarbonate or calcium with no clear indicationNeglect to use backboardNeglect to use stepstoolNeglect to place defibrillator pads to enable real‐time feedbackEpinephrine given <every 3 minEpinephrine given >every 5 min
Institutionally defined error, based on new standards	No Quality CPR coach assignedDefibrillator not placed directly across from the compressorDefibrillator not placed on the same side as the patient monitorTurning patient >1 time (ie, do not coordinate placement of backboard and placement of back pad)Delay in use of end‐tidal carbon dioxide (within 30 s of turning on defibrillator that has ETCO2)Delay in activation of ECMO (goal of 5 min after chest compressions started, if ROSC not yet achieved)Prolonged pause in chest compression when moving patient from Emergency Medical Services gurney to Emergency Department bed

BMV indicates bag‐mask ventilation; ECMO, extracorporeal membrane oxygenation; ROSC, return of spontaneous circulation.