Advanced closed-loop communication training: the blindfolded resuscitation

Hughes, Kate; Hughes, Patrick G.; Cahir, Thomas M; Plitt, Jennifer; Ng, Vivienne; Bedrick, Edward J.; Ahmed, Rami

doi:10.1136/bmjstel-2019-000498

Cited by 2 publications

(2 citation statements)

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“…Firstly, the management of anaphylaxis is often characterized by inappropriate dosing and timing of epinephrine as a first-line medication [ 4 , 9 , 10 ]. This might indicate a need for high-fidelity simulation and training for anaphylaxis and CPR in special circumstances [ 2 , 32 ] and for organizational measures like standardization of code medications and prefilled or pre-labelled syringes [ 8 , 33 ]. Second, crew resource management elements (e.g.…”

Section: Discussionmentioning

confidence: 99%

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A potentially lifesaving error: unintentional high-dose adrenaline administration in anaphylaxis-induced cardiac arrest; a case report

Hans,

Benning,

Pooth

et al. 2024

Int J Emerg Med

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Background Cardiopulmonary resuscitation is a crucial skill for emergency medical services. As high-risk-low-frequency events pose an immense mental load to providers, concepts of crew resource management, non-technical skills and the science of human errors are intended to prepare healthcare providers for high-pressure situations. However, medical errors occur, and organizations and institutions face the challenge of providing a blame-free error culture to achieve continuous improvement by avoiding similar errors in the future. In this case, we report a critical medical error during an anaphylaxis-associated cardiac arrest, its handling and the unexpected yet favourable outcome for the patient. Case presentation During an out-of-hospital cardiac arrest due to chemotherapy-induced anaphylaxis, a patient received a 10-fold dose of epinephrine due to shortcomings in communication and standardization via a central venous port catheter. The patient converted from a non-shockable rhythm into a pulseless ventricular tachycardia and subsequently into ventricular fibrillation. The patient was cardioverted and defibrillated and had a return of spontaneous circulation with profound hypotension only 6 min after the administration of 10 mg epinephrine. The patient survived without any residues or neurological impairment. Conclusions This case demonstrates the potential deleterious effects of shortcomings in communication and deviation from standard protocols, especially in emergencies. Here, precise instructions, closed-loop communication and unambiguous labelling of syringes would probably have avoided the epinephrine overdose central to this case. Interestingly, this serious error may have saved the patient’s life, as it led to the development of a shockable rhythm. Furthermore, as the patient was still in profound hypotension after administering 10 mg of epinephrine, this high dose might have counteracted the severe vasoplegic state in anaphylaxis-associated cardiac arrest. Lastly, as the patient was receiving care for advanced malignancy, the likelihood of termination of resuscitation in the initial non-shockable cardiac arrest was significant and possibly averted by the medication error.

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Section: Discussionmentioning

confidence: 99%

“…Second, crew resource management elements (e.g. closed-loop communication, read-backs, call-outs) [ 32 , 33 ] should be a bedrock component in professional development for all healthcare workers. Additionally, these measures must be embedded in error-preventing environments on organizational levels [ 16 , 34 ].…”

Section: Discussionmentioning

confidence: 99%