Non-traumatic cardiac arrest is a critical condition, and errors and safety incidents during resuscitation reduce patient survival rates. Systematic investigations of patient safety incidents during resuscitation are limited. This systematic review aimed to examine the characteristics and nature of patient safety incidents during real and simulated resuscitation.

We searched MEDLINE, EMBASE, Web of Science, CINAHL Complete, Cochrane, Google and Google Scholar using keywords such as “cardiac arrest”, “resuscitation” and “system error” and related boolean operators “AND” or “OR”. Only papers published in English between 2020 and May 2024 and fulfilled pre-defined eligibility criteria were included. Data were extracted, and the results were synthesized using thematic analysis.

Nineteen resuscitation studies were included in this review. There were 8 real and 11 simulated resuscitation, published between 2020 and 2024. Five common themes were identified for both resuscitation types. They included 1) Timely activation of the resuscitation call procedures, 2) medication incidents, 3) equipment incidents, 4) suboptimal application of technical skills, and 5) suboptimal application of nontechnical skills. Three unique themes were identified for actual resuscitation: 1) unclear goals of care status, 2) failure to adequately assess patients, and 3) appropriate location for resuscitation. Two unique themes; system issues and suboptimal case management, were identified for simulated resuscitations.

This systematic review identified a range of types of patient safety incidents that occur during non-traumatic cardiac arrest resuscitation which can be categorised thematically to aid stakeholders in addressing the potential for latent safety issues effecting resuscitation.

Cardiac arrest

Resuscitation

Patient safety

Survival

© 2025 The Authors. Published by Elsevier Inc.