WEBINAR: Healthcare SIG
Understanding the Human Factors Related to Unrecognised Oesophageal Intubation Using the SEIPS Framework
Pilot study of airway equipment preparation tray - Melody Chen, B. L. William Wong
Te Whatu Ora, Health New Zealand, 'Auckland University of Technology, New Zealand
Summary Unrecognised oesophageal intubation (UOI) is a medical procedural error in which a breathing tube is mistakenly placed into the esophagus and not promptly identified or addressed. A literature review on the human factors relating to UOl was performed and findings presented in the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Key themes relating to issues around intubation equipment factors were used to inform the design of a cognitive aid to improve human performance in this clinical context. A semantically meaningful tray consisting of images and uniquely sized slots was created and sought to address technical and non-technical human factors identified in adverse event reports and coronial cases of UOI.