Why does oesophageal intubation still go unrecognised? Lessons for prevention from the coroner’s court

Pandit, J. J.; Young, Peter; Davies, M.

doi:10.1111/anae.15634

Cited by 22 publications

(25 citation statements)

References 22 publications

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“…Our patient airways are now ‘shared’, intubation changed from ‘me to we’, our team hierarchy is flatter and teamwork and trust enhanced. The authors noted the crowded anaesthetic room described by the coroner [1, 2]. Consistent with NAP4 and NAP5 recommendations, we have not used anaesthetic rooms for the induction of anaesthesia for over 20 years and would not revert to their use.…”

Section: Figurementioning

confidence: 54%

“…We read with interest the editorial by Pandit et al. [1] regarding unrecognised oesophageal intubation [2]. We understand Glenda Logsdail's case involved ‘misinterpretation’ of capnography without ‘sustained exhaled carbon dioxide’ soon becoming flat, with the anaesthetist focusing instead on a Grade 1 laryngoscopy view, loss of situation awareness and fixation on one diagnosis (here, anaphylaxis).…”

Section: Figurementioning

confidence: 98%

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Unrecognised oesophageal intubation: additional human factors and ergonomics solutions

Kelly

Cook

2022

Anaesthesia

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regarding unrecognised oesophageal intubation [2].We understand Glenda Logsdail's case involved 'misinterpretation' of capnography without 'sustained exhaled carbon dioxide' soon becoming flat, with the anaesthetist focusing instead on a Grade 1 laryngoscopy view, loss of situation awareness and fixation on one diagnosis (here, anaphylaxis). We would like to add to the authors' solutions included in the editorial.Considering 'engineered solutions', we suggest industry alters the capnograph trace on monitors to shade the area under the curve as already seen on some monitors (Fig. 1). This helps distinguish the capnograph trace from the ventilator airway pressure waveform (Fig. 2), reportedly an issue in Glenda Logsdail's case [2]. We advocate 'universal videolaryngoscopy', which has benefits for skill acquisition, teamwork, communication, non-technical skills

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Section: Figurementioning

confidence: 54%

Section: Figurementioning

confidence: 98%

Unrecognised oesophageal intubation: additional human factors and ergonomics solutions

Kelly

Cook

2022

Anaesthesia

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“…As reported in the inquest "There was evidence of an inhibitory hierarchical structure which prevented others shouting out" [11]. The case and the human factors involved in the sad outcome are further discussed in a recent editorial [12].…”

Section: Discussionmentioning

confidence: 97%

“…As reported in the inquest “ There was evidence of an inhibitory hierarchical structure which prevented others shouting out ” [11]. The case and the human factors involved in the sad outcome are further discussed in a recent editorial [12]. While there is extensive literature dealing with challenging authority in business and psychology [13, 14], research into the medical field is still lagging behind [15].…”

Section: Discussionmentioning

confidence: 99%

Deception in simulation‐based education: a randomised controlled trial of the effect of deliberate deception on the performance of anaesthesia trainees

et al. 2022

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Summary The use of deliberate deception in simulation allows for a level of realism that is not normally feasible. However, the use of deception is controversial, and carries the risk of psychological harm to learners. There are currently no quantitative data on the effect of deception on learner performance, making it difficult to judge its usefulness. The objective of this study was to examine the impact of deception on learners' performance during a life‐threatening scenario. In this simulation study, second‐year anaesthesia residents were randomly allocated into two groups: the non‐deception group was told that the participating consultant was acting a part, while the deception group was told that the consultant was a subject in the study. Learners then participated in a simulated crisis that presented them with situational opportunities to challenge the consultant regarding clearly wrong decisions. Two independent raters scored the performances using the modified advocacy‐inquiry scale. Forty‐four participants were analysed. The median (IQR [range]) highest scoring modified advocacy‐inquiry scale was 5.0 (4.5–5.1 [4.0–5.5]) for the non‐deception group and 4.0 (3.0–4.0 [2.5–5.0]) for the deception group, (p < 0.001), and the median total number of challenges per participant was 26.8 (21.0–31.1 [16.5–35.5]) and 18.0 (14.3–23.3 [7.0–33.0]), respectively (p = 0.001). Trainees exposed to deliberate deception, who thought that the consultant anaesthetist was a subject, had a less‐effective best challenge, likely mimicking real‐life behaviour. Deliberate deception appears to modify behaviour, particularly relating to communication involving hierarchical relationships. This technique may improve authenticity, especially with a steep power gradient, and so has demonstrable value which must be balanced against the ethical considerations.

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“…We congratulate Pandit et al. on their editorial on unrecognised oesophageal intubation [1], which was written in response to a tragic case in August 2020. We would like to comment and also offer some further thoughts on preventing a similar tragic event happening again.…”

mentioning

confidence: 99%