Table 4.

Peer expert and analyst-identified judgement failures for CMPA closed cases, 2007–2016 (n = 46 cases)

	N (%)
Inappropriate difficult airway management
Failure to use supraglottic airway as a bridge	1 (2)
Perseveration	5 (11)
Failure to plan for difficult airway management (induction)	7 (15)
Delay in calling for, or failure to call for, a surgical airway	2 (4)
Inadequate preoperative or airway evaluation	27 (59)
Number of judgement failures
None of the above (appropriate management)	16 (35)
1	20 (43)
2–5	10 (22)

CMPA = Canadian Medical Protective Association.