Patient Safety: Lessons Learned
Unanticipated Death During Intubation at UK Hospital
By: Alexis Victoria Murshed RN MBA CPHRM CLNC, Director of Patient Safety Operations, Stanford Center for Advancing Patient Safety (CAPS)
Even the most routine procedures can lead to unexpected complications.
A 32-year-old wife and mother entered a prestigious medical center in the United Kingdom for an elective tonsillectomy being performed at the Ambulatory Surgery Unit. The surgeon explained to the patient and her husband that she would be able to go home by the afternoon. The procedure began uneventfully until the anesthesiologist attempted to intubate the patient. Within minutes, the anesthesiologist realized that he was not able to secure the airway due to swelling and requested assistance from the surgeon. The two physicians struggled while two nurses stood by with a tracheostomy kit in the ready. Minutes passed and the struggle to obtain an airway continued. The situation was critical as the patient was already given a paralytic and had no ability to self-ventilate.
Finally, the airway was secured after 20 minutes, and to the horror of the physicians, too much time had passed. The procedure was aborted, and the patient was taken to the Post-Procedure Care Unit where she was assessed by a neurologist. Diagnostic tests showed the patient had suffered permanent anoxic brain injury. After serious consideration, the decision was made by the patient’s husband and her family to discontinue life-support. The patient passed away the next morning.
Lessons Learned:
- The anesthesiologist and surgeon lost situational awareness.
- The nursing staff was fully aware of the need for an emergency tracheostomy and had the kit ready, but was afraid to speak up.
- The culture did not provide psychological safety for the staff to speak up.
- There was an absence of a formal escalation process for the OR staff to report dire situations.
How to prevent a similar occurrence:
- Flatten the hierarchy and provide psychological safety to all team members and staff.
- Speak up when there is doubt and stop the line.
- Start procedures with a quick pause to give permission to all team members to speak up if they have concerns.
- Request a verbal time-check at a set interval when appropriate (i.e. every 2 minutes during rescue).