SummaryWe reviewed all patient safety incidents reported to the UK National Patient Safety Agency between August 2006 and February 2007 from intensive care or high dependency units. Incidents involving equipment were then categorised. A total of 12 084 incidents were submitted from 151 organisations (median (range) 40 (1-634) per organisation). Of these, 1021 incidents were associated with use of equipment, most commonly involving syringe pumps ⁄ infusion devices (185 incidents), ventilators (164 incidents), haemofilters (107 incidents) and monitoring equipment (70 incidents). Twenty-nine incidents were associated with more than temporary harm to patients. Failure or faulty equipment was described in 537 incidents (26% with some harm) and incorrect setting or use was described in 358 incidents; these were more likely to be associated with harm (39%; p = 0.001). We suggest changes to improve the reporting of incidents and to improve equipment safety.

Summary Temporary and permanent tracheostomies are required in children to manage actual or anticipated long‐term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

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