Patient Safety Alert
Resultant Harm to the Patient
A patient required increased oxygen, ventilator support, sedation and paralytics when the wrong-size cuffed tracheostomy tube was inserted. Upon recognition that the size of the cuffed tube (inner diameter) was not as intended, the tracheostomy tube was changed to what was ordered and appropriate for the patient.
Actions to Mitigate Risk at Your Hospital
- Communicate and validate the tracheostomy tube specifics (brand, cuff, inner and outer diameter size) with all team members prior to all tracheostomy tube insertions.
- Communicate and validate the tracheostomy tube type (brand, cuff, inner and outer diameter size) during hand-offs.
- Review and validate supply cart stocking processes to ensure that all tracheostomy tubes are placed in their respective labeled locations. Audit carts daily for accuracy.
- Review prior wrong-size tracheostomy tube events in your organization. If events have brands in common, initiate processes to ensure clarity of product labeling. (The review at the reporting hospital found the same brand of cuffed tracheostomy tubes was involved. This was reported for product labeling concerns).
- Patient Safety
- Risk Management
- Cause Analysis Staff
- Organizational Leaders
- Perioperative and Otolaryngology Clinical Leaders
There are multiple numbers on the packaging of pediatric cuffed tracheostomy tubes. The tube selected was stocked incorrectly in the labeled supply cart. Care providers relied on other team members for the selection and verification of the correct tracheostomy tube. There was inadequate verification of the inner diameter of the tracheostomy tube size prior to insertion. The outer diameter size of the tracheostomy tube size was assumed to be the inner diameter intended.
Contact Kate Conrad, vice president, (913) 981-4118 or Barbara Weis, project specialist, (913) 981-4117.