Year : 2012  |  Volume : 6  |  Issue : 3  |  Page : 259-262

Inadvertent endobronchial intubation: A sentinel event

1 Department of ENT and Head & Neck Surgery, College of Medicine, King Khalid University, Abha, Saudi Arabia
2 Department of Anesthesia & Intensive Care, Continuous Quality Improvement & Patient Safety, Armed Forces Hospitals Programme-Southern Region, Khamis Mushayt, Saudi Arabia
3 Department Anesthesia & Intensive Care, Armed Forces Hospitals Programme-Southern Region, Khamis Mushayt, Saudi Arabia

Correspondence Address:
Ali S Al-Qahtani
Vice Dean for Clinical Affairs, College of Medicine, King Khalid University, Abha
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-354X.101218

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Background: Unintentional bronchial intubation may result in serious complications such as lung collapse or pneumothorax. These complications amount to sentinel events should be reported, and a hospital sentinel event policy should be implemented, including corrective actions to prevent recurrence. Methods: A 12-month prospective observational study in a multidisciplinary adult intensive care unit (ICU) to estimate the frequency of inadvertent bronchial intubation and its major sequels in intubated patients admitted to the unit. Complications will be reported as sentinel events attracting investigation by root cause analysis method, action plan, and follow-up. Results: There were 36 (12.9%) cases of inadvertent bronchial intubations in 279 orally-intubated patients admitted to the ICU during the study period (1.5.2010 - 30.4.2011), 2 (0.7%) of them already developed total left lung collapse. The hospital sentinel event policy was activated followed by action plan, which included raising the awareness of the problem, presentations, and regular checking on the position of the tube following tracheal intubation at different location in the hospital. Conclusion: Early detection and correction of endobronchial intubation will prevent complications developing. Applying sentinel event policy on complications of inadvertent bronchial intubation will encourage finding permanent solution to an old and preventable problem. Anesthetic and resuscitative regulatory bodies should incorporate methods of checking on correct position of tracheal tubes in their training programs. Knowing that the tube may advance into a bronchus, they should insist on regular checking of the tube in a manner similar to monitoring patient's vital signs.

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