Patient Safety Alert
Subject: Airway Management
Adverse events in airway management are over-represented in the EMER database. Currently, 11% of EMER reports(30/270) involved an incident relating to intubation. All incidents in the EMER database are coded into categories. The most common types of airway incidents are CICO (‘can’t intubate, can’t oxygenate), medication errors and delay to decision to intubate. Outcomes included unrecognised oesophageal intubation, surgical airway, cricothyroidotomy and 5 deaths (16.7% of airway incidents).
Advanced airway management remains a high risk procedure in Emergency Departments. To reduce errors a number of strategies can be utilised including equipment standardisation, simulation, selection of experienced practitioners, and use of a pre-intubation checklist and difficult airway algorithm.1
Patient Safety Alert No. 3 06/09/2016. Follow us on Twitter at @EmerMedER Information obtained from Emergency Medicine Events Registry - an online, anonymous incident reporing system for Emergency Department doctors in Australia and New Zealand. Contact [email protected]. Reference: 1. Fogg et al, The Royal North Shore Hospital Emergency Department airway registry: closing the audit loop.. Emergency Medicine Australasia. (2016) 28, 27–333