Lessons learnt from incidents involving the airway and breathing reported from Australasian emergency departments

Abstract

Recommendations for improving preparedness of ED staff and facilities have been made for each of the problem areas identified with respect to clinical practice, equipment, communication and clinical process. Analysis of incidents from the Australasian Emergency Medicine Events Register allows clusters of like-events to be identified and characterised, providing the possibility of getting a better idea of how problems present and progress, with some information about contributing factors, characteristics and context. This will pave the way for earlier and better detection of life-threatening problems and the development and reinforcement of preventive and corrective strategies.

Current airway management practices after a failed intubation attempt in Australian and New Zealand emergency departments

“…The DAS recommendations included a maximum of three attempts at tracheal intubation; repeated attempts with no changes in personnel, patient positioning, laryngoscope or adjunct devices were not recommended 12 . A similar Australian analysis of 36 reported incidents with complications in ED airway management identified key lessons to improve communication, planning and equipment preparation which were consistent with the recommendations of the NAP4 study, including the mandatory use of capnography 13 …”

A BRILL idea? The benefits, risks, insights, learning and limitations of an emergency airway registry in pre‐hospital and retrieval medicine

“…Collation of information about these rare or infrequent events, their identification and management may allow for realistic and focussed education packages to be developed for targeted groups of clinicians. Reporting of these rare events within a single system may have a beneficial cognitive effect on individual clinicians . Learning from the practice of others on a regular basis can facilitate the development of meta‐cognition and may improve both individual and team performance…”

“…Reporting of these rare events within a single system may have a beneficial cognitive effect on individual clinicians. 21 Learning from the practice of others on a regular basis can facilitate the development of metacognition and may improve both individual and team performance. 22…”

Error and safety in Emergency Medicine

“…This includes a taxonomy of ED incident types and contributing factors . Subsets of incident types, such as diagnostic, procedural and medication error can be collated and analysed . Rare but catastrophic incidents can be examined and learnings disseminated via Patient Safety Alerts .…”