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Unrecognised oesophageal intubation: time for action
Paul A Baker1, Ellen P O'Sullivan2, Michael F Aziz3
1Department of Anaesthesiology, University of Auckland, Auckland, New Zealand; Department of Paediatric Anaesthesia, Starship Children's Hospital, Auckland, New Zealand.
British Journal of Anaesthesia
|October 3, 2022
Summary
Unrecognised oesophageal intubation, a fatal airway management error, continues despite advancements. This review examines strategies to prevent this avoidable complication, aiming to improve patient safety worldwide.
Area of Science:
- Medical Safety
- Anesthesiology
- Patient Care
Background:
- Unrecognised oesophageal intubation is a critical, yet avoidable, complication in airway management.
- This error, often due to human factors, leads to preventable patient mortality globally.
- It occurs irrespective of patient age or practitioner experience.
Discussion:
- Despite advancements in monitoring technology and airway devices, oesophageal intubation remains a persistent risk.
- Medical education and training in airway management require continuous improvement to address this issue.
- Human error is the primary driver, highlighting the need for robust safety protocols.
Key Insights:
- The incidence of unrecognised oesophageal intubation persists despite technological and educational progress.
- A systematic review of current improvements and preventative strategies is crucial.
- Eliminating this complication requires a multi-faceted approach focusing on human factors and system safeguards.
Outlook:
- Future strategies must integrate enhanced vigilance and standardized protocols to eradicate oesophageal intubation.
- Continued research into human factors and device design can further mitigate risks.
- The ultimate goal is to achieve zero preventable deaths from this specific airway management error.
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