Tracheostomy and Laryngectomy Airway Safety Events: An Analysis of Patient Safety Reports From 84 Hospitals
Background: Tracheostomy- and laryngectomy-related airway safety events can lead to life-threatening situations, permanent harm, or death. We conducted a statewide population-based study to learn about these events and the relationship with associated factors, interventions, and outcomes to identify...
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| Format: | Article |
| Language: | English |
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Patient Safety Authority
2022-03-01
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| Series: | Patient Safety |
| Online Access: | https://doi.org/10.33940/data/2022.3.3 |
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| _version_ | 1850153365186543616 |
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| author | Lea Anne Gardner Rebecca Jones Christopher H. Rassekh Joshua H. Atkins |
| author_facet | Lea Anne Gardner Rebecca Jones Christopher H. Rassekh Joshua H. Atkins |
| author_sort | Lea Anne Gardner |
| collection | DOAJ |
| description | Background: Tracheostomy- and laryngectomy-related airway safety events can lead to life-threatening situations, permanent harm, or death. We conducted a statewide population-based study to learn about these events and the relationship with associated factors, interventions, and outcomes to identify potential areas for improvement.
Methods: We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) to find tracheostomy- and laryngectomy-related airway safety event reports involving adults age 18 years and older that occurred between January 1, 2018, and December 31, 2020.
Results: Reports related to tracheostomies and laryngectomies accounted for 97.3% and 2.7% of the total, respectively. The four most frequent tracheostomy-related complications were unplanned decannulations, 71.4%; uncontrolled bleeding/hemorrhage, 9.2%; and partial/total occlusion and mucus plug/thick secretions, which each accounted for 6.9%.
Conclusions: Safe airway management for patients with a tracheostomy or laryngectomy requires staff who are knowledgeable and confident, and have the necessary skills and equipment to provide immediate attention when complications arise. We discuss potential safety strategies to reduce the risk of unplanned decannulations, uncontrolled bleeding/hemorrhage, and partial/total occlusions, as well as issues related to equipment, knowledge/training, and communication. |
| format | Article |
| id | doaj-art-097f9bfdbd834b458b962fd828ddbd17 |
| institution | OA Journals |
| issn | 2689-0143 2641-4716 |
| language | English |
| publishDate | 2022-03-01 |
| publisher | Patient Safety Authority |
| record_format | Article |
| series | Patient Safety |
| spelling | doaj-art-097f9bfdbd834b458b962fd828ddbd172025-08-20T02:25:44ZengPatient Safety AuthorityPatient Safety2689-01432641-47162022-03-014110.33940/data/2022.3.3Tracheostomy and Laryngectomy Airway Safety Events: An Analysis of Patient Safety Reports From 84 HospitalsLea Anne GardnerRebecca JonesChristopher H. RassekhJoshua H. AtkinsBackground: Tracheostomy- and laryngectomy-related airway safety events can lead to life-threatening situations, permanent harm, or death. We conducted a statewide population-based study to learn about these events and the relationship with associated factors, interventions, and outcomes to identify potential areas for improvement. Methods: We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) to find tracheostomy- and laryngectomy-related airway safety event reports involving adults age 18 years and older that occurred between January 1, 2018, and December 31, 2020. Results: Reports related to tracheostomies and laryngectomies accounted for 97.3% and 2.7% of the total, respectively. The four most frequent tracheostomy-related complications were unplanned decannulations, 71.4%; uncontrolled bleeding/hemorrhage, 9.2%; and partial/total occlusion and mucus plug/thick secretions, which each accounted for 6.9%. Conclusions: Safe airway management for patients with a tracheostomy or laryngectomy requires staff who are knowledgeable and confident, and have the necessary skills and equipment to provide immediate attention when complications arise. We discuss potential safety strategies to reduce the risk of unplanned decannulations, uncontrolled bleeding/hemorrhage, and partial/total occlusions, as well as issues related to equipment, knowledge/training, and communication.https://doi.org/10.33940/data/2022.3.3 |
| spellingShingle | Lea Anne Gardner Rebecca Jones Christopher H. Rassekh Joshua H. Atkins Tracheostomy and Laryngectomy Airway Safety Events: An Analysis of Patient Safety Reports From 84 Hospitals Patient Safety |
| title | Tracheostomy and Laryngectomy Airway Safety Events: An Analysis of Patient Safety Reports From 84 Hospitals |
| title_full | Tracheostomy and Laryngectomy Airway Safety Events: An Analysis of Patient Safety Reports From 84 Hospitals |
| title_fullStr | Tracheostomy and Laryngectomy Airway Safety Events: An Analysis of Patient Safety Reports From 84 Hospitals |
| title_full_unstemmed | Tracheostomy and Laryngectomy Airway Safety Events: An Analysis of Patient Safety Reports From 84 Hospitals |
| title_short | Tracheostomy and Laryngectomy Airway Safety Events: An Analysis of Patient Safety Reports From 84 Hospitals |
| title_sort | tracheostomy and laryngectomy airway safety events an analysis of patient safety reports from 84 hospitals |
| url | https://doi.org/10.33940/data/2022.3.3 |
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