Patient safety: unrecognised oesophageal intubation
Patient safety lies at the heart of healthcare. It is one of the most significant concerns across the NHS and independent sector and is a key priority for the College. A key factor to driving forward patient safety is maximising the things that go right and minimising the things that go wrong. Learning from mistakes by addressing systemic factors in order to prevent future harm is essential to improving patient safety.
Unrecognised oesophageal intubation
The College has received a coroners report where an oesophageal intubation took place and was not recognised in time to save the life of the patient. Unrecognised oesophageal intubation is preventable through adherence to published recommendations on the monitoring of exhaled carbon dioxide (capnography) and its correct interpretation. The College endorses the Preventing unrecognised oesophageal intubation consensus guidelines produced by the Project for Universal Management of Airways.
For the latest advice on preventing unrecognised oesophageal intubation, please watch the talk below by Prof Tim Cook from the Anaesthesia Updates event in September 2024:
Multidisciplinary team training
Multidisciplinary team training has an important role to play in rehearsing emergency drills, embedding non-technical skills in practice and allowing teams to learn how to function well as a whole within a flattened hierarchy. We have developed the following resources to support departments to deliver team training:
We recognise that time is the biggest barrier to team training and have thus developed three short, flash card simulations to enable this to be delivered as a talk-through scenario in 5 minutes. We ask all departments to use these flash cards on the subject of unrecognised oesophageal intubation and to provide us with feedback.
The flashcards can be downloaded here
The Royal United Hospital Bath have developed a package of tea trolley training to support this campaign, which is available to download below:
- Introduction and learning objectives
- What tea trolley training is and how it works
- Tea Trolley tool kit V6
- Capnography tea trolley teaching tool and handout
- Capnography Tea Trolley Teaching Plan 5 and 10 minute options
- Capnography Quiz Cards
- Capnography tea trolley training attendance register
- Capnography tea trolley training feedback form
- Certificate blank word document -adjustable for each hospital
- Making Training Fun
More information about the campaign can be found in the following articles:
RCoA Bulletin January 2022 Issue
Anaesthesia News January 2022 Issue
SALG recommendation for capnography positioning and appearance on monitoring screens
SALG has released a recommendation on capnography positioning and appearance on monitoring screens with the aim of preventing unrecognised oesophageal intubation. The statement can be read on SALG's website SALG Statement on Waveform Capnography
Coroners Report
Here you can find three coroners reports on unrecognised oesophageal intubation:
Coroners report September 2021 - an updated response from the Association, College and DAS is available here
No trace = wrong place
We previously launched the popular No Trace = Wrong Place campaign to highlight the correct use of capnography to prevent undetected oesophageal intubation.
All clinicians involved in airway management should watch the College and DAS video on capnography. We ask that they always remember 'No Trace = Wrong Place' and actively seek to exclude oesophageal intubation when a flat capnograph trace is encountered.
This short video is only seven minutes long - perfect to watch on your coffee break:
Video resources
We have a collection of videos that are highly informative and worth sharing with your colleagues.
Articles
Read the Bulletin articles
- Flashcard simulation helps tackle unrecognised oesophageal intubation, digital Bulletin October 2022
- We are all human but together we can prevent unrecognised oesophageal intubation, Bulletin January 2022 (PDF below)
If you have any queries about our patient safety workstream, please contact us