Table 2.

Procedural safety pitfalls, solutions sought and lessons learned for future prevention.

Case No	Safety pitfall	Impact of error	Solution sought	Lesson learned
1	None	N/A	N/A	N/A
2	Early patient transfer to theatre	Surgical team not donned	Surgical team scrubbed in the anaesthetic Room	Improve communication with anaesthetic/transfer team
3	Malfunctioning inner radio	Impaired communication with outer team	Loud voice/signs	Check radio prior to procedure
4	ET Tube advanced too far caudally	Single lung ventilation	Measure ET tube prior to proceeding	Do not begin tracheostomy unless confirmation that ET tube is in appropriate position
5	None	N/A	N/A	N/A
6	None	N/A	N/A	N/A
7	2 members of anaesthetic team to be at head end for ET tube manipulation	Loss of fluency of ET tube manipulation at a critical point	Mandatory 2 members of anaesthetic team to be at head end at time of ET tube manipulation	Better direction to anaesthetic team
8	ET tube balloon pierced. Pt had a history of previous tracheostomy	Had to keep ventilator off and place tracheostomy tube immediately	Number 11 blade to be used	Broader blade used to create window. Use an 11 blade
9	None	N/A	N/A	N/A
10	None	N/A	N/A	N/A