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Intubation Mishap

Matthew B. Weinger, MD; George T. Blike, MD | September 1, 2003
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Case Objectives

  • To understand and apply a structured method of human factors case analysis
  • To describe the key components of effective teamwork
  • 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 failure.

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 2. (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 participants.(6)

Failures of Interpersonal Communication in Health Care.—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 coordination.

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 say.(8) 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 implicit.(11) 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 understood.(12)

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 situations.

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 Medicine 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 Medicine 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).


1. Vincent C, Taylor-Adams S, Chapman E, et al. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ. 2000;320:777-781[ go to PubMed ]

2. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316:1154-7[ go to PubMed ]

3. Katzenbach JR, Smith DK. The wisdom of teams: creating the high performance organization. Cambridge, MA: Harvard Business School Press; 1993.

4. Kanki BG, Lozito S, Foushee HC. Communication indices of crew coordination. Aviat Space Environ Med. 1989;60:56-60[ go to PubMed ]

5. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23:294-300[ go to PubMed ]

6. Surgenor SD, Blike GT, Corwin HL. Teamwork and collaboration in critical care: lessons from the cockpit. Crit Care Med. 2003;31:992-3[ go to PubMed ]

7. Loftus E. Reconstructing memory: the incredible eyewitness. Psychol Today. 1974;8:116-119.

8. Tannen D. The power of talk: who gets heard and why. Harvard Business Review. 1995;73:138-48.

9. Birdwhistell RL. Kinesics and context: essays on body motion communication. Philadelphia, PA: University of Pennsylvannia Press; 1970.

10. Mehrabian A. Silent Messages: implicit communication of emotion and attitudes. Belmont, CA: Wadsworth Publishing Co.; 1981.

11. Xiao Y, Mackenzie CF, Patey R, et al. Team coordination and breakdowns in a real-life stressful environment. Proceedings of the Human Factors and Ergonomics Society (HFES) 42nd Annual Meeting. 1998;42:186-190.

12. Gaba DM, Fish K, Howard SK. Crisis management in anesthesiology. New York, NY: Churchill Livingstone; 1994.

13. Dreyfus HL, Dreyfus SE, Athanasiou T. Mind over machine: the power of human intuition and expertise in the era of the computer. New York, NY: The Free Press; 1986.

14. Endsley MR. Measurement of situation awareness in dynamic systems. Hum Factors. 1995;37:65-84.

15. Gaba DM, Howard SK, Small SD. Situation awareness in anesthesiology. Hum Factors. 1995;37:20-31[ go to PubMed ]

16. Gaba DM, Howard SK, Fish KJ, Smith BE, Sowb YA. Simulation-based training in anesthesia crisis resource management (ACRM): A decade of experience. Simul Gaming. 2001;32:175-193.

17. Helmrich RL, Davies JM. Anaesthetic simulation and lessons to be learned from aviation. Can J Anaesth. 1997;44:907-12[ go to PubMed ]

18. Holcomb JB, Dumire RD, Crommett JW, et al. Evaluation of trauma team performance using an advanced human patient simulator for resuscitation training. J Trauma. 2002;52:1078-86[ go to PubMed ]

19. Small SD, Wuerz RC, Simon R, Shapiro N, Conn A, Setnik G. Demonstration of high-fidelity simulation team training for emergency medicine. Acad Emerg Med. 1999;6:312-323[ go to PubMed ]

20. Beckman AW, Sloan BK, Moore GP, et al. Should parents be present during emergency department procedures on children, and who should make that decision? A survey of emergency physician and nurse attitudes. Acad Emerg Med. 2002;9:154-158[ go to PubMed ]

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 recovery.

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

Contributory Factor Type

Putative Role in this Case

Risk Priority (see figure)

Patient Factors



Patient condition

Acute respiratory distress in infant


Clinician-patient communication

N/A in this case


Availability and accuracy of test results



Task Factors



Task design and clarity of structure

Intubation task steps not explicit


Availability and use of protocols

No intubation protocol in place?


Practitioner Factors



Knowledge, skills, rules

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



Possibly decreased in supervising MD



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 drugs/procedure


Team structure and leadership

Leadership/followership suboptimal; Roles unclear


Working Conditions



Staffing levels, skill mix, and workload

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


Availability and maintenance of equipment



Administrative and management support

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





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 Factors



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 risk


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 organization.


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 anticoagulated.

Delayed transmission

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

Wrong information transmitted

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

Ambiguous or incomplete information transmitted

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

Failure of Message Reception


Message not heard

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

Wrong information heard

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

Information misunderstood

Pharmacist 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 drug.

Failure of Message Acknowledgement


Failure to acknowledge receipt

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

Failure to acknowledge understanding

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

Failure to state when action taken

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


Figure. Risk Analysis Matrix

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 case.


View Video


Good Communication

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


View Video

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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