Cases & Commentaries

Intubation Mishap

Spotlight Case
Commentary By Matthew B. Weinger, MD; George T. Blike, MD

Case Objectives

  • To understand and apply a structured method
    of human factors case analysis
  • To describe the key components of effective
  • To understand the importance of and barriers
    to effective interpersonal communication
  • To appreciate how to design effective
    interventions (including simulation) to address deficiencies in
    teamwork and communication

Case & Commentary

A 17-month-old female infant
in the pediatric intensive care unit (PICU) developed acute respiratory

While setting up the
laryngoscope and endotracheal tube, the PICU physician gave a verbal order
for atropine, etomidate, and rocuronium. Shortly thereafter, but prior to
intubation, the infant acutely desaturated. The team realized the patient
received the paralytic agent prematurely. She was immediately intubated
without difficulty and her respiratory status was stabilized.

Upon review of the event, the
team discovered that the nurse, who was new to the PICU, had not realized
the medication was a paralytic agent and thus administered it before the
intubation tray was ready, resulting in the infant’s desaturation.
The physician who ordered the medication had not indicated the timing of
administration or that the medication was to be drawn up but not given
until later.

In this case, a child suffered a hypoxic episode because
she was paralyzed prematurely during an urgent, but not emergent,
intubation procedure. We will review this case using a human factors
approach (1,2),
the overall goal of which is to identify threats to patient safety and then
devise strategies to minimize the risk to future patients. The steps in the
process are listed in Table 1, and a checklist for contributory factor analysis is
detailed in Table
. (Please refer to Figure for explanation of risk priority assigned in Table 2.)

Teamwork and Communication
This case illustrates an unfortunately common occurrence in health care:
flawed teamwork related to deficiencies of interpersonal communication.
Based on work in the business arena (3), Weinger has proposed that effective teamwork in
the health care setting requires the presence of the "5 C’s" outlined
in Table 3. In
the present case, one might be tempted to give the team a failing grade on
three of the five C’s: Competence, Communication, and Coordination.
Coordination is dependent on effective communication.(4)

The Evidence for Communication Failures.—In
one ICU study, failures of communication between team members accounted for
37% of all errors reported during a 4-month period, yet represented only 2%
of task activities documented during a 24-hour direct observation
period.(5) In
ongoing anesthesia patient safety research in San Diego, CA, communication
failures contributed to 16% (20 of 98) of operating room events reported by
the primary clinicians when directly queried by a researcher (nearly 90%
were reported within 2-4 hours of the end of the case). In a separate study
(Weinger, et al., unpublished work), communication or coordination issues
played a role in about 11% of 118 actual operating room events captured
during more than 700 hours of direct observation and videotaping. At
Dartmouth-Hitchcock Medical Center, failures of team communication were
identified in 61% of the 42 events that have been reviewed by the Sentinel
Event Committee over the last 4 years. Differences in incidence across
studies and settings reflect different methods, definitions, and review
criteria, and may reflect different interpretations by nurse and physician

Failures of Interpersonal Communication in Health
.—Although physicians and other health care professionals
spend many years learning an impressive array of scientific information and
skills, health care curricula largely omit topics such as interpersonal
influence and group dynamics, organizational behavior, negotiation, or
conflict resolution. The increasing use of standardized patients is a
welcome addition to health care professional education but does not address
issues of deficient provider–provider communication and

The increasing complexity of modern medicine means that
care is now being provided by teams of individuals. The diversity of modern
teams adds to the challenge: individual team members will differ, not only
in their training and degrees, but also in their values, needs, and
cultural or other expectations. Working effectively as a team member
requires training and practice. Perhaps recent changes in expectations of
the Accreditation Council for Graduate Medical Education (ACGME) and other
health care regulatory bodies about clinician competency in interpersonal
skills will begin to address this serious issue.

It´s Not Just What You Say.—How
you say something will affect whether the intended recipient understands
and acts appropriately on the message. In both realistic simulations and
actual patient care, it is common to see clinicians bark out instructions
(eg, "Get an IV in this guy") without any direction as to who should
do it. Extensive research in social psychology shows that words, as well as
their order and timing, will all affect how other people respond.(7) Vocal cues (rate,
tone, pitch, volume, emphasis of speech) typically contain 20%-40% of the
overall message. Tannen has documented clear gender differences in both
communication style and understanding of what others mean by what they
Communication is not just verbal—perhaps up to 50% of the "message"
is conveyed in nonverbal behavior (facial expression, body posture and
movement, eye contact, etc.).(9,10) Effective team communication involves unspoken
expectations, traditions, assumptions about task distribution, command
hierarchies, as well as individual emotional and behavioral components.
Xiao and colleagues recently showed that highly skilled trauma teams
communicated in a variety of ways, many of which were nonverbal and
However, nonverbal cues are even more susceptible to misinterpretation, due
to changing context or differences in gender and culture.

Taxonomy of Communication Failures.—There
are many types of communication failures and many ways to classify them.
Fundamentally, they can be broken down into failures of message
transmission and reception. Table 4 provides a comprehensive taxonomy. Work in Crew
Resource Management (CRM) has revealed that team communication markedly
improves with the use of "read-back" or other
techniques to acknowledge that a message has been received and

Clinical Competence
Clinical competence involves more than knowledge and technical skills. In
the complex care environment, one also needs to know when and how to apply
knowledge, solve problems, make good decisions, communicate effectively,
and work as part of a team. Clinical experience does not always equate with
clinical expertise: with improper training, one can learn very well how to
do something incorrectly. Additionally, expertise is not an unchanging
personal property but a dynamically varying relationship between
environmental demands and that person’s resources to cope with those
demands at that particular time.(13) For example, an anesthesiologist, who is an
accomplished laryngoscopist in the operating room, may find her skills
lacking when trying to manage a difficult airway in a remote location with
poor lighting, awkward patient positioning, or without the usual equipment
and support.

The Importance of Situation Awareness.—In
this case, the PICU physician was apparently not aware of the competence of
the assisting nurse, nor was he aware of the status of the drugs that had
been "ordered" until after the infant desaturated. The accepted term for a
comprehensive and coherent cognitive representation of the current clinical
situation, continuously updated based on repetitive assessment, is
situation awareness (14,15), which appears to be an essential prerequisite for
safe operation of any complex, dynamic system. In anesthesia, surgery, or
critical care, adequate "mental models" of the
patient and the associated care environment (clinical facilities,
equipment, personnel, etc.) are essential to effective situational
awareness. Acute care clinicians must be able to recognize clinical cues
quickly and completely, detect patterns of cues, and set aside cues that
are distracting or less relevant. Even in less acute settings, situation
awareness about the actions, thoughts, and intentions of other team members
is critical to effective teamwork.

The Importance of Preparation.—In this case,
the induction drugs were administered before the intubation equipment was
ready. The patient suffered no harm, but this near miss points to the
importance of being prepared for unexpected events. Clinicians need to
anticipate the risks of each situation and strive to structure the care
environment preemptively to reduce their occurrence and impact.
Preparedness is paramount in high tempo, high risk domains like
anesthesiology and critical care. Optimal response in crisis situations
requires not only availability of the necessary equipment and drugs, but
also mental and physical readiness. Excellent clinicians prepare themselves
for all possible scenarios and their risks by mentally simulating what both
patients and team members might do (or not do) in different clinical

Designing Effective Interventions to Address
Deficiencies of Teamwork and Communication
The goal of a formal case review should be to identify threats and
facilitate the design of countermeasures, creating enhanced safety for the
next patient. Crew Resource Management training, used in the aviation
industry to train members of the flight deck, has become a model for team
training in some sectors of medicine. David Gaba and colleagues have been
instrumental in adopting CRM to the anesthesia domain, termed Anesthesia
Crisis Resource Management Training (ACRM).(12,16) High fidelity patient simulation
typically plays a key role in CRM-oriented team training because
realistically recreating the complexity of the clinical environment helps
assure that the behaviors and lessons learned are transferred to real
patient care. Such simulators can be calibrated to the needs of the team;
some can recreate incidents that provoke performance failures among even
the best of clinicians.(17-19) Such simulations give groups a safe setting in which to
practice the full range of effective teamwork behaviors such as task
allocation, read-backs, closed-loop communication, and clarifying roles and
responsibilities for each team member. Simulated exercises are usually
videotaped to facilitate the critical structured debriefing sessions in
which performance failures are reviewed and lessons learned.

One of the limitations of using simulation more broadly
in health care has been the expense of setting up a facility (eg, in
addition to a dedicated and usable facility, the cost of a patient
simulator will be $30,000 to $200,000, and clinical and video equipment
might be $10,000 to $100,000), the cost of conducting simulation courses
(including the cost of relieving instructors and trainees from regular
clinical duties), and the small number of learners that can have a truly
hands-on experience at any one time (typically less than 8 in a group).
Nonetheless, many academic medical centers, including ours, have created
Simulation Centers to enhance clinical training. Both of our groups have
been conducting simulator-based "mock codes." At Dartmouth, simulated
pediatric sedation events are conducted to "stress test" various clinical
settings where sedation care is provided. Although more than 300
individuals provide this care at Dartmouth-Hitchcock Medical Center, no
more than 20 clinicians participate in each mock code. Thus, to broaden the
learning from each simulated sedation exercise, videos demonstrating code
reenactments are sent to all 300 providers over the hospital
internet—essentially an internet debriefing for a large audience. If
efficacy can be established, dissemination models like these should prove
useful for hospitals and providers unable to afford simulation centers or
to support their complex logistics.

Using simulation in the PICU at the Children’s
Hospital at Dartmouth, we closely emulated this case in two videos.
[Limited by the constraints of the plastic mannequin simulator, the case
involves a 6-year-old instead of a neonate. In addition, we took the
creative license to include an additional putative contributory factor
(that may or may not have been present in the original case) of parental
presence and involvement because this is increasingly common in PICUs and
has been suggested to play a role in some accidents.[20]] The first video is titled "Poor
Communication" (Video 1) and might be what happened in this case, with the
caveats described above. The second video is titled "Good Communication"
(Video 2) and
is meant to show how communication might have been different if the
clinicians had all participated in a team-based CRM course. Take particular
notice of how the ICU physician and nurse communication differs (both in
terms of confirming that the order was understood and seeking clarification
of intent) as you watch the two 3-minute videos.

This case nicely illustrates the fact that errors are
increasingly due to failures in communication and teamwork. Traditional
training models, such as lectures and readings, can play only a limited
role in preventing these errors. Moreover, isolated training silos
(training doctors and nurses about teamwork in separate rooms) will not
help diverse professionals learn to work together as a team during crisis
situations. The use of CRM, video simulations, role-plays, and other
innovative training models will be needed to tackle communication and
teamwork errors.

Matthew B. Weinger, MD
Director, Center for Healthcare Simulation of the San Diego Center for
Patient Safety
Professor of Anesthesiology, University of California, San Diego School of
Staff Physician, VA San Diego Healthcare System
San Diego, CA

George T. Blike, MD
Director, Dartmouth Medical Interface Laboratory
Associate Professor of Anesthesiology and OB/GYN, Dartmouth College of
Staff Anesthesiologist, Children’s Hospital at Dartmouth and
Dartmouth-Hitchcock Medical Center
Hanover, NH

Faculty Disclosure: Dr. Weinger and Dr. Blike
have declared that neither they, nor any immediate members of their
families, have a financial arrangement or other relationship with the
manufacturers of any commercial products discussed in this continuing
medical education activity. In addition, their commentary does not include
information regarding investigational or off-label use of pharmaceutical
products or medical devices.

Acknowledgements: We would like to thank Jens
Jensen, Joseph Cravero, and Dartmouth’s Pediatric ICU nursing and
respiratory therapy staff that supported the creation of the videos used to
supplement this article.

Funding/Support: Dr. Weinger was supported by
grants from the Agency for Healthcare Research and Quality (AHRQ
P20-HS11521 and R01-HS11375) and the Department of Veterans Affairs (HSRD
IIR 20-066). Dr. Blike was supported by a grant from the National Institute
for Child Health and Human Development (NICHD RO3-HD041229).


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21. Reason J. Human Error. Cambridge: Cambridge
University Press; 1990.


Table 1. Five Stages in
Reviewing an Error Using a Human Factors Approach

1. Contact the person reporting the
event to gather a more complete representation of the what,
when, and how of the event (interviews of participants are
often necessary).

2. Review the incident for Management
Problems: did care deviate beyond safe limits; and if so, did
deviation have potential to cause patient harm?

3. Perform a Contributory Factor
Analysis using a checklist of items (see Table 2).

4. Prioritize the contributory
factors that pose a significant threat based on the risk
analysis matrix first proposed by Reason.(21)

5. Design and implement
countermeasures to actively "manage" this and similar errors.
The intent of the countermeasures is error trapping and error

Table 2. Categorization of
Possible Contributory Factors in Medical Event Investigations (and,
specifically, in this case)

Contributory Factor Type

Role in this Case

Priority (see figure)

Patient Factors



Patient condition

Acute respiratory distress in


Clinician-patient communication

N/A in this case


Availability and accuracy of test



Task Factors



Task design and clarity of

Intubation task steps not


Availability and use of protocols

No intubation protocol in place?





Knowledge, skills, rules

Inexperienced nurse, did not know the
medications ordered or their effects



Possibly decreased in supervising



Verbal order; No briefing on goals,
threats, plans and roles/responsibilities


Motivation and attitude



Physical or mental health



Team Factors



Verbal or written communication

Statement into "thin air"; Verbal
order incomplete; No briefing


Supervision, seeking help

Inexperienced nurse with incomplete
training; Did not seek help when did not know


Team structure and leadership

Leadership/followership suboptimal;
Roles unclear


Working Conditions



Staffing levels, skill mix, and

Nursing shortage has led to higher
turnover with younger/less experienced nurses or those
unfamiliar with unit


Availability and maintenance of



Administrative and management

Orientation and training of nurses on
high-risk unit and for high-risk procedures may be





Financial resources

ICU under significant financial
constraints (could limit staff training time)


Goals, policies, and standards

Probably not a factor


Safety culture and priorities

Reactive culture (eg, address
problems only when they occur) - Proactive approach would be
simulated drills


National/Public Health



Economic and regulatory issues

All ICUs (especially pediatric) are
inadequately reimbursed for expenses. Simulation training is
expensive and no source of support


Health policy and politics



Medical liability

Pediatric ICU especially high


Table 3. The Five "C´s" of
Effective Teamwork in Health Care*

Common goal

Every team member shares and
understands the short- and long-term goals of the team and the


Every team member is committed to
attaining the goals.


Every team member has the knowledge,
skills, behaviors, and attitudes necessary to accomplish
successfully their role in the team´s activities.


Team members communicate effectively
and efficiently with each other, with the patient, and with
other parties (whether animate or inanimate) through whatever
means are required to accomplish desired goals.


Team members efficiently and
effectively work together and with other needed technology,
people, and resources to accomplish desired goals.

* Refined by Weinger for health care based on work by
Katzenbach and Smith (3) and others.

Table 4. Taxonomy of
Communication Failures

Type of
Communication Failure


Failure of
Message Transmission


Failure to inform

ICU doctor
fails to inform the anesthesiologist doing an emergency nasal
intubation that the patient in respiratory failure is

Delayed transmission

test results relevant to therapeutic decision are "lost" for
several hours.

Wrong information transmitted

Jones had an MI a week ago" when it was Mr. Smith in the
adjacent bed who had the MI.

Ambiguous or incomplete information

states "give rocuronium" without specifying dose, route, and/or

Failure of
Message Reception


Message not heard

environment of ED or ICU prevents team members from hearing
attending´s instructions.

Wrong information heard

heard "give epinephrine" instead of "give ephedrine."

Information misunderstood

heard "give ephedrine" but thought it was for Mr. Smith instead
of Mrs. Jones.

Failure to act on message

Distraction leads to delay or failure to give requested

Failure of
Message Acknowledgement


Failure to acknowledge receipt

Anesthesiologist fails to acknowledge surgeon’s request
that heparin be administered.

Failure to acknowledge

member responds with "uh huh" rather than explicit read back of
instructions given.

Failure to state when action

action acknowledged but either not taken or delayed and not
stated when completed.


Figure. Risk Analysis Matrix

This is a simplified risk analysis matrix that shows the
relationship between the severity of the outcome of an actual or possible
event and the likelihood of its occurrence (or reoccurrence). In general,
events which fall in the A to C categories (intermediate to high risk and
moderate to severe severity) are those requiring active efforts to prevent
or mitigate.








Poor Communication

Might be what happened in this


View Video


Good Communication

How communication might have been
different if the clinicians had all participated in a
team-based CRM course.


View Video