The Science Journal of the American Association for Respiratory Care

2011 OPEN FORUM Abstracts


Leane R. Soorikian, Susan Ferry, Joseph Bolton; Respiratory Care, Children's Hospital of Philadelphia, Philadelphia, PA

Background: Our department provides approximately 992 new and replacement tracheostomy tubes for infants and children annually. Variation in tube brand, size, length, flange type, absence or presence of cuff, type of cuff and custom template use increases the variables that may introduce risk of error and injury. Electronic error reporting validated our concerns. We determined to improve safety and eliminate preventable harm for our tracheostomy patients. Method: Our multidisciplinary Airway Advisory Committee developed a safety checklist, "time out," to be followed prior to all routine tracheostomy tube changes in the Newborn Infant Intensive Care and Progressive Care Units, the areas with the highest use of tracheostomy tubes. Using the checklist, appropriate tracheostomy parameters, as well as team roles and elements of Universal Protocol are reviewed, then documented on the checklist. After piloting, an iterative checklist was created which modeled the surgical safety checklist used for procedural time outs. Headings for pre-procedure, prior to procedure start, and after procedure complete were used to imitate format. RTs and RNs were trained during a skills fair and return demonstrated understanding and competent use of the checklist was validated. Results: Tracheostomy tube placement and change errors were significantly reduced. In our NIICU, we recorded 16 errors and reduced safety process defects to our current tracking which shows 339 days since our last tracheostomy tube related error. Conclusions: Tracheostomy related safety events benefit from tracking to identify risk and current safety practice. Established safety initiatives, such as a time out checklist as was used in our case, can be applied to improve safety or eliminate risk for never events in respiratory care practices despite the lack of published outcomes for specific, RT-sensitive safety indicators. Sponsored Research - None