The 10 Most Common CPR Mistakes Made by Clinicians

Author: Kaleb Lachenicht, Chief Clinical Officer of ROCKET and Director Epic EM

And how they quietly reduce survival.

One of the uncomfortable truths about cardiac arrest care is this:

Even trained clinicians frequently perform sub-optimal CPR, despite the training, practice and focus on the basics!

Common CPR Mistakes: Subtle Errors with Significant Impact

In simulation studies, real arrests, and quality monitoring systems, the same problems appear again and again. These mistakes are rarely dramatic, but they quietly reduce perfusion to the heart and brain.

In cardiac arrest, small physiological changes matter enormously.

Below are ten of the most common CPR mistakes seen in clinical practice, knowing about these errors may help us to prevent them in our teams.

1. Compression Rate That Is Too Fast

Many clinicians believe faster compressions generate more circulation. In reality, compressions that exceed 120/min often result in:

• shallower compressions

• incomplete chest recoil

• poor coronary perfusion

When teams get stressed during resuscitation, compression rate often drifts up to 130–150/min.

Unfortunately, this reduces effective perfusion

The Fix

Use a metronome at 110 bpm, and practice using one in sim so that it becomes the standard!

2. Compressions That Are Too Shallow

Even trained providers frequently fail to reach the recommended depth.

Guidelines recommend:

• 5–6 cm depth in adults and 1/3 AP diameter in the paed or infant

Common reasons compressions become shallow include:

• rescuer fatigue

•  fear of rib fractures

• poor positioning over the sternum

• mattress compression

Shallow compressions significantly reduce cardiac output.

Remember:

Rib fractures are common and acceptable, inadequate perfusion is not.

3. Leaning on the Chest (Incomplete Recoil)

This is one of the most under-recognised CPR problems. Leaning between compressions prevents full chest recoil, which increases intrathoracic pressure and reduces venous return to the heart, as well as myocardial perfusion. Without venous return, there is no preload, and therefore no forward blood flow during the next compression. Even small amounts of leaning can significantly reduce circulation.

The Fix

Coach compressors actively:

“Push hard, come completely off the chest.”

4. Interrupting Compressions Too Often

Every time compressions stop:

• Coronary perfusion pressure immediately falls to zero.

• When compressions restart, it takes several compressions to rebuild perfusion pressure.

Common causes of unnecessary pauses include:

• rhythm checks that are too long

• airway attempts

• defibrillator preparation (not pre-charging the machine

• team confusion

Best practice:

• Keep rhythm checks <10 seconds (have someone actually count them down)

• charge defibrillator while compressions continue

• resume compressions immediately after shock

5. Hyperventilation

This is one of the most common errors in advanced resuscitation teams and is also one of the more difficult ones to get right. Clinicians frequently ventilate patients far faster and with more volume than recommended. Excess ventilation increases intrathoracic pressure, which reduces venous return and cardiac output.

Recommended ventilation:

Without advanced airway

• 30:2 compressions to breaths

With advanced airway

• 10 breaths per minute (1 breath/6 seconds)

Many studies show providers ventilate at 20–30 breaths per minute during arrest.

This significantly impairs circulation.

6. Delaying Defibrillation

For shockable rhythms, early defibrillation is one of the most effective interventions in resuscitation.

But teams often delay shocks due to:

• prolonged rhythm analysis

• uncertainty about rhythm

• waiting for airway placement

• anxiety around the use of the defibrilattor

Best practice is simple:

If VF or pulseless VT is identified:

• Defibrillate immediately and resume compressions

• Set up each rhythm check as though a defibrillation will occur!

7. Poor Team Coordination

Many CPR failures are not technical problems, they are team performance problems.

Common issues include:

• unclear leadership

• simultaneous airway and rhythm checks

• confusion around roles

• delayed compressor rotation

High-performing teams typically assign roles early:

• team leader

• compressor

• airway

• defibrillator operator

• medication nurse

Clear structure improves CPR quality dramatically.

8. Failing to Rotate Compressors

Compression quality deteriorates quickly due to fatigue.

Even experienced providers show reduced depth after: 1–2 minutes

Despite this, teams often delay switching compressors because:

• they want to “push through”

• team organisation is poor

• space constraints exist

• they don't realise how important it is

Guidelines recommend switching compressors every 2 minutes, this should happen during rhythm checks to avoid extra pauses.

9. Poor Patient Positioning

CPR effectiveness is strongly influenced by patient positioning.

Common problems include:

• soft mattresses

• inadequate backboards

• awkward rescuer positioning

• access to the patient

Mattresses absorb compression force and reduce effective depth.

Whenever possible:

• use a backboard

• ensure rescuer shoulders are directly over the sternum

• lock elbows and use body weight

• the patient is moved to a space where access is clear

10. Focusing Too Much on Advanced Interventions

During resuscitation it is easy to become distracted by the "fun stuff"

• intubation

• IV access

• medications

• ultrasound

But these interventions are secondary to maintaining circulation.

High-performing teams prioritise:

1️⃣ Continuous compressions

2️⃣ Early defibrillation

3️⃣ Controlled ventilation

4️⃣ Then advanced interventions

The most dangerous distraction during arrest is airway obsession, a poorly timed intubation attempt can cause prolonged pauses in compressions. A supraglottic device often pulls this task fixation away!

The Retrieval Perspective

For retrieval clinicians, these problems can become even more pronounced.

Aircraft and ambulance environments introduce unique challenges:

• limited space

• small teams

• difficult patient access

• prolonged resuscitation periods

Strategies that help include:

• mechanical CPR devices for transport

• strict role allocation

• metronome-guided compressions

• early planning for compressor rotation

In retrieval medicine, CPR quality is often the limiting factor in resuscitation success.

The Bottom Line

Most CPR failures are not caused by a lack of knowledge, they are caused by small technical errors that reduce perfusion.

The most important elements of good CPR remain simple:

• Compression rate 100–120/min

• Compression depth 5–6 cm

• Full chest recoil

• Minimal interruptions

• Controlled ventilation

• Frequent compressor rotation

In cardiac arrest, survival is often determined by how well we perform the basics.

References

American Heart Association. 2020. Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation.

Idris, A.H. et al., 2012. Relationship between chest compression rates and outcomes from cardiac arrest. Circulation.

Kleinman, M.E. et al., 2015. Part 5: Adult Basic Life Support and CPR Quality. Circulation.

Meaney, P.A. et al., 2013. CPR quality: improving cardiac resuscitation outcomes. Circulation.

Stiell, I.G. et al., 2012. Chest compression fraction and survival after out-of-hospital cardiac arrest. Circulation.

Perkins, G.D. et al., 2021. European Resuscitation Council Guidelines for Resuscitation. Resuscitation.