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Checklist and cognitive adds in emergency settings

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Checklist and cognitive adds in emergency settings

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Accepting that we all health workers can make mistakes during stressful situations, helps us to be more aware of different kind of tools available, to accept the opinion of another colleague even a junior one, to delegate and ask for help when we cannot handle a specific task when required. This also creates a strong team that support each other to provide the best care to any patient.

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An example of where algorithms and checklist became vital was during the height of Covid where circumstance of risk changed the paradigm and increased the complexity of the airway procedure. New algorithms and checklists with added features allowed safe intubation for both patient and intubator. Human factors and new ideas were needed to accommodate the changed environment.

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Standardised airway trolleys and visible difficult airway algorithms improve safety by reducing delays and confusion during emergencies. Conversely, poorly organised equipment or unclear team communication can lead to wrong device selection, delayed intubation attempts, and increased risk of hypoxia during airway management.

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Improves preparation (Algorithms & Checklists)

Paramedics can follow structured airway algorithms and checklists before attempting airway procedures. This ensures important steps such as preparing oxygen, suction, airway devices, and drugs are not missed in emergencies. This will ensure good communication is maintained between the crew at all times .

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Failure happens when the SHO / reg feels they cannot question the consultant, or offer suggestions.

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In the airway management the clinician’s brain is under extreme cognitive load. This is where the ARACHNID model, specifically Design and Non-Technical Skills, comes into play through color-coding.

During a difficult airway, an anesthetist is focused on the patient's vocal cords or falling oxygen saturations. They do not have the time or the enough concentration to read small black-and-white text on a syringe. The brain processes color significantly faster than text. By using standardized colors (e.g., yellow for induction agents like propofol, red for muscle relaxants like succinylcholine), the system offloads the cognitive work from the "slow" analytical brain to the "fast" intuitive brain.

A common error is the accidental administration of a muscle relaxant to a patient who is still awake or not yet ventilated.

If a nurse or assistant sees the doctor picking up a syringe with a blue label (opioid) when they meant to grab a Yellow one (induction), the color code allows the assistant to speak up immediately. It is easier to spot a "wrong color" than a "wrong word" from across the room.

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Applying Human Factors and Ergonomics (HFE) principles has a significant impact on patient safety, especially in high-risk situations such as airway management. For example, using standardized checklists and cognitive aids before intubation helps ensure that essential equipment and drugs are prepared and reduces the risk of omissions under stress. Proper ergonomic positioning of the patient, the operator, and the equipment also improves visualization and reduces physical strain, which contributes to better performance.

Clear role allocation and closed-loop communication within the team are further examples of HFE principles that enhance safety, particularly in emergency situations. When each team member understands their responsibilities, tasks are performed more efficiently and errors are less likely to occur.

In contrast, a lack of consideration for HFE can increase the risk of complications or near misses. Examples include poor workspace organization, unavailable or unfamiliar equipment, fatigue, time pressure, and unclear leadership. These factors may lead to delayed airway management, incorrect drug administration, or failed intubation attempts. Recognizing and addressing these human and system-related factors is essential to improving patient safety.

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Team communication & cognitive load management

Effective airway management isn’t just about technical skills — it’s about teamwork and situational awareness. During stressful situations like failed intubation, clear communication, defined team roles, and cognitive offloading through checklists can dramatically reduce fixation errors and improve patient safety.

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Algorithms , communication and checklist

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Algorithms , communication and checklist

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We are more tuned to concept of having checklist, planning and communication and algorithms. Having a dedicated person assigned in a crisis situation will help team dealing with a difficult scenarios to offload the cognitive overload which happens under stressful situations and avoiding fixation errors.

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In the pre-hospital environment having standardised checklists and algorithms helps to mitigate risk and errors. These two elements are particularly useful in this setting as airway management is often unpredictable and teams don't often have the opportunity to assess the patient prior to needing an intervention (i.e. pre-op assessments etc.).

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Sometimes the lack of incidents reporting can lead to a loss of airway safety management, probably due to a lack of teaching and practising among difficult and non-previst situations.

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The designs have allowed us to make greater improvements to safety all around. the designs are something that are still continuing to develop and change which means that in the future safety can become even better than it is now

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Having simple, effective algorithms readily available in all theatres/ all locations where intubation is performed is vital. In the event of a difficult airway a brief glance or being aware that the DAS guidelines are available is reassuring and ensures correct sequence of a difficult airway

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Having standardised kit has helped impact safety. And using algorithms and checklists helping step by step procedures

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As I currently work on emergency frontline 999 response I can utilize the HFE Checklist from the spider web algorithm by checking that my vehicle is in a safe working condition prior to driving in emergency conditions. This not only allows the inspection of the vehicle itself but safety and compliance for me as the "driver" and knowing that a step by step process has been followed. This will in turn limit any incidents or near misses that may occur.

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It is important to have a clear plan and communicate this. Communication is not only key before the task but also and most importantly DURING. In the confusion and breakdown that leads to an adverse event, persons may become less efficient for a multitude of reasons.

One major factor that helps with this would be levelling the field. Unfortunately, in certain settings this may not be a welcomed proposition, especially for senior colleagues (as I have experienced). This can make for an unsettling environment when catastrophe strikes.

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All the outlined criteria are important, however a key element is the ability of the staff present to say “I cannot do this” or “maybe we should abandon the procedure.”

Trying unsuccessfully for too long instead of adhering to the algorithm can have fatal consequences.

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HFE

allows for an organized approach to airway management, utilizing designs, algorithms, resilience, tools, and non-technical skills.

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Open up to colleagues the aims and objectives of the airway management. Encourage colleagues to speak up if they notice a change in the Patient, situation or monitoring. Pre hospitally it is common to be drawn in to a skill and overlook other aspects of HFE.

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Clear role assignment during airway management is essential. When each team member knows their responsibilities: who leads, who manages the airway, who administers drugs, who monitors. efficiency improves, stress is reduced, and critical steps are less likely to be missed, especially in emergencies.

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Yes, consideration of Human Factors and Ergonomics (HFE) is fundamental to improving airway management safety. One example where HFE contributes positively is during team briefings before induction of anaesthesia, especially in high-risk cases such as patients with obesity. Taking a few minutes to assign clear roles, review the airway plan, prepare backup equipment, and confirm that all team members feel empowered to speak up creates a safer environment and improves outcomes.

On the other hand, I’ve witnessed situations where the lack of HFE awareness has contributed to near misses,for example, when a difficult airway cart was not available in the room, or when communication failed due to assumptions about who was managing the airway. In these cases, the team was unprepared for an evolving crisis, and time was lost due to poor coordination.

HFE reminds us that safety is not just about technical skill, but also about environment, communication, cognitive load, and system design.

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When not implemented or are rushed these can lead to unsafe situations in recovery. e.g. reporting "ASA1 and fit to go home" for a post-op patient with an artificial airway without mentioning any challenges experience in the initial airway placement is not good enough. This may occur due to system pressures to rush cases but can be highly detrimental for the patient at hand at time of airway removal.

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Checklists have always helped me to ensure safety precautions are in place in an environment. I usually start with a physical checklist and once I'm more comfortable will go through it in my head

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Devising a plan and then allocating roles according to a clear strategy is of great help. In special airway situations, having the airway lead heading the team and briefing each and every member of the team ahead of the task can be very helpful. The basic necessity is that the each team member has been trained and they are all familiar with the technology available and are aware what is expected to be the next step in the plan. A clear line of communication and explanation to the patient what they will go through, for example, in AFOI, is quite rewarding.

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All through medical school we are taught to use mnemonics to remember all the content we have to master, particularly the difficult material.

I still use this method especially during high stressful environments. I work at a referral hospital and the theatre's are packed with posters that have algorithms pertaining to common emergencies that occur.

For example in the maternity theatre there is large poster with the algorithm pertaining to neonatal resuscitation and airway management. The ENT theatre has an algorithm pertaining difficult airway, this is very helpful to eyeball and remind oneself about the steps missed.

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We put bedheads and algorithms for tracheostomy emergencies (from the National Tracheostomy Safety Project) at the bedspace of each tracheostomy patient in the ICU. These act as cognitive aids and algortithms.

We also did simulation training for new staff to the ICU regarding the management of tracheostomy emergencies.

See link for the National Tracheostomy Safety Project algorithms and bedheads here:

Tracheostomy

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I am currently working as FY1 and I can see in everyday practice how human mistakes and HFE can have huge adverse impact on patient's safety.

For example, towards the end of the shift and during handover after a long and busy shift, if you have overlooked or forgot an important patient or job to handover it poses huge risk to patient's safety. Or my colleague had a situation where a patient was moved to a different bed and this was not updated in the system. The consultant rounding on the patient was seeing the record for the wrong patient and subsequently the medications prescribed was wrong.

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The use of checklists prior to intubation provides a quick confirmation that all of the equipment, back up equipment, monitoring and drugs are all thought about and ready. The best use of them (B@EASE in my trust) is as an initial shopping list to make sure all of the equipment is gathered, then verbalising the checklist prior to the procedure so that everyone else is aware of the availability. It limits unexpected complications

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Handover is something that is overlooked in anaesthesia as there often isn't a structured or scheduled handover. It's crucial that key airway issues / concerns are included in handover for breaks and take over of care so the receiving clinician can prepare and plan for any issues that may arise. In my observations this is an area that is often lacking in anaesthetic practice.

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I find it very helpful to explicitly go through the airway plan before any case including any anticipated difficulties, required equipment, next steps and if appropriate when I would like the other team members to get help. This is part of the WHO checklist at my hospital but I find is often done cursorily due to time pressures if there are no particular issues anticipated

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Having a flattened hierarchy and having those in charge open up the floor for others to be able to raise ideas and concerns and create a shared team mental model is vital to be able to address possible errors, as people with different experience levels and backgrounds may spot different things that could be wrong or improved

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When one's brain is going a hundred miles an hour in stressful situations, it can be difficult to be able to slow down an follow a checklist logically. I think it is important to make using checklists a standard in training, so the act of reaching for one becomes 2nd nature.

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HFE ensures that with airway management, the equipment is standardised and colour coded- as well as being laid out correctly. This refers to the 'cognitive aids' section of ARACHNID. This will help to reduce the chance of human error in an emergency as you will be able to choose the right equipment quickly, reducing patient harm, without being confused- increasing efficiency.

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When I was working in a place where they punish the doctor who has had experience of bad outcome, no one could ask for help or report an incident then no progress. But when the team are supportive and transparent, they can progress well.

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Simulation education especially multidisciplinary in situ has made a big impact on making NTS more explicit.

The value of teams knowing each other cannot be overstated but is not always possible. Clear, concise communication without hierarchy is key.

Cognitive aids especially standardised are becoming more widely acceptable.

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making use of algorithms make things function in a proper manner and easier to identify the effectiveness of action and make proper further reviews and studies, great team work and being open to alternate suggestion and action helps in improving the outcome ,anyway proper settings and equipment's are important which everyone is aware of. Human and equipment factors are things which needs attention

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Both the technical and non technical skills are  very important in enhancing airway skills and safety.

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Both the technical and non technical skills are  very important in enhancing airway skills and safety.

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Use of algorithms, checklists , teamwork , appropriate communication among team members will aid appropriate airway management and hence safety of the patients involved

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I think that the doctor should have heard out the nurse. Considering they are a team and all have similar educations they should bounce ideas off of each to her. The doctors should take advantage of the anesthetic assistants to standardize the airway carts in the room. This as well as the checklist of items in the room would allow for a safer and easier process. If your in a rush to find things it causes danger for the patient

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as a prehospital Paramedic I attended an Asthmatic Cardiac arrest where the patient had collapsed on the phone during as Asthma Attack, I was working on an ambulance and we were backing up a Solo responder who had managed to make it to scene 10 minutes prior to our arrival.

on arrival we had found that the patient had 3x attempts of ETI - repeating the same process and not changing their approach - whilst a family member was performing (and struggling) with Chest Compressions.

After changing the plan and communicating that the same technique was not working, we decided to go through the airway ladder.

After managing the patient with positioning, then using a supraglottic device, and performing needle thoracentesis, we achieved ROSC, Enhanced care was summoned and performed an RSI with an appropriate ventilatory strategy.

Feedback was delivered with learning and improvement created.

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An important aspect is being an approachable person that members of the team feel comfortable to offer suggestions/alternative strategies when the current strategy isn't working. This would allow for more efficient movement onto the next step int he strategy and can help to bring the airway lead back to the overall situation

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Being aware of human factors may lead to moving roles if the senior/most capable clinician may be working suboptimal on any days. The understanding of teams to not doubt capability from passing the task to someone else helps create a culture where everyone can feel less pressured if they feel unsure of managing a task and being able to be supported by other capable members who might be fresher/better rested.

Also ergonomics allow for optimal performance by reducing pressure of poorly located/complicated systems being in place. It also streamlines performance by allowing tasks to be performed easier from good planning and preparation of equipment and working spaces.

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Example of HFE contributing to safety in airway matters 

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Example of HFE contributing to safety in airway matters 

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Design of Medical Equipment

1. Intuitive design of laryngoscopes: Ergonomic design of laryngoscope handles and blades to reduce fatigue and improve visibility.

2. Standardization of connectors: Standardizing connectors for airway devices to prevent misconnections and reduce errors.

Workspace and Environmental Design

1. Optimized workspace layout: Designing the workspace to minimize clutter, ensure easy access to equipment, and reduce distractions.

2. Adequate lighting: Providing sufficient lighting to facilitate visualization of the airway.

Human Factors Engineering

1. Reducing cognitive load: Simplifying airway management protocols and checklists to reduce cognitive load and minimize errors.

2. Standardized communication: Implementing standardized communication protocols to ensure clear and effective communication among team members.

Training and Education

1. Simulation-based training: Providing simulation-based training to improve airway management skills and reduce errors.

2. Regular skills assessment: Conducting regular skills assessments to identify areas for improvement and provide targeted training.

Error Prevention and Mitigation

1. Checklists and protocols: Implementing checklists and protocols to ensure that all necessary steps are taken during airway management.

2. Error-correcting mechanisms: Establishing error-correcting mechanisms, such as debriefing sessions, to identify and learn from errors.

These examples demonstrate how applying Human Factors and Ergonomic principles can contribute to safer airway management practices.

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It is really important to have non techinical skills to function efficently in a health care system.Proper communication with the team members and seeking help from the colleagues is really important.

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Consultants dictating the the environment

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Consultants dictating the the environment

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I'm an FY2. Was on an anaesthetics taster week and there was a surgical consultant who ran his department in quite a chaotic manner -> very loud music, was very in people's face. It was "tolerable" and I don't know how much he knew how it affected his colleagues - the bit I want to reflect it on is the cumulative effect of his attitude and how the theatre was run when he was there. It created an element of mental fatigue when he was working, ultimately people were more likely to make mistakes in this environment. A consultant should be a bedrock that everyone builds around to create a good team structure. If you are unprofessional or create a chaotic atmosphere that is ultimately going to have effects on your team.

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I think that in the end, my mind's eye wanders back to the Prof. Tim Cook paper and the NAP4 findings - for example, he notes that tracheostomies weren't being considered for pts under local anaesthesia + there were delays in transfers where surgeons were integral parts of the backup plans; poor judgement, skills and training were the 3 most highlighted retroactively to the NAP4. Thankfully, there've been lots of changes since then, but we can all benefit from things like continual training, checklists, algorithms and guidelines, peer to peer support and knowing when to hand over, when to switch techniques, devices and so on!

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It is crucial to have standardised algorithms next to the emergency trolley. This should be in good sight of the team leader. Simple but crucial checks as monitoring blood sugars can often be missed in an emergency situation when one becomes fixated on the most imminent difficulty. Hence preparing of the trolleys and repeated practice is vital.

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As an ODP who has worked in both private sector theatres and NHS, I find it would be an advantage to anaesthetic assistants such as nurses and ODP's to standardise airway trolleys in the anaesthetic room as has been achieved with the difficult airway trolley. This along with a checklist of items for each drawer would make practise easier and safer. All too often these trolleys are crammed with too many items making it difficult to find things in a hurry, as well as items being in different drawers in different theatres.

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When looking at the breakdown of communication, especially if you take the Elaine Bromley case as an example, it is not just a breakdown of communication but ego that plays a vital role in the errors that occurred. When you hear that 80% of second attempt intubations with the same method fail, what would lead us to reattempt the same method other than ego and trying to prove you are right. It is also what likely played a role in the nursing staff who brought the trachy airway kit to not feel they could raise that this was the next step. Ego is one of the biggest factors that impacts on not just airway management errors but errors in all aspects of healthcare.

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As seen in the case of Elaine, if the anesthetist had listened to the nurse, then maybe there could have been a better outcome. So, I believe flattening of the hierarchy contributes to positive Human factor, as it also empowers all the members of the team.

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I love a checklist as a leveller - a fixed value regardless of experience/qualifications/time served, with roles and tasks for everyone, dovetailing nicely with some of the ideas around good leadership & followership, especially during crisis situations.

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I feel like that Checklists are not used enough despite it being created already. It will help streamline the process and create a safe environment and maintain ongoing consistency.

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As a pre-hospital paramedic, I attended a cardiac arrest from a drowning. A workable arrest, but due to hypothermia, core temp <34 degrees C, Adrenaline administration times should be increased to 6-10 minutes. A Hazard Area Response Paramedic arrived mid incident and proceeded to try and administer Adrenaline. Not senior to myself, but thought that they were, but I told them not to give the adrenaline. They ignored me. I told them again. They ignored me. The third time, I shouted loudly and they looked so confused that I had shouted. They were clearly so distressed and concentrating that they heard but did not register what I was saying. A classic example of Human Factors with stress being high on the list. The Adrenaline was given appropriately but not without difficulty.

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Reality between two different countries 

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Reality between two different countries 

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I was trained in a LMIC, then I moved to a high income country.

During my residence, I realised we had several problems in the ED regarding airway management. Therefore, we developed an airway bundle, with collaborations from nurses, ICU doctors, anaesthetics to develop not only a checklist, but an airway trolley. Since predictors of difficult airway are not so reliable in the ED. We believe that it would be better to have a plan always prepared to face a difficult airway.

And for my surprise, where I am right now we have similar strategies, long time implemented and accepted as part of the culture, which is the most difficult part to change I believe.

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As a more junior member of the team, understanding and feeling an environment in which the hierarchy has been flattened is empowering to be able to speak up and feel able to challenge any scenarios that may impact patient safety

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As a trainee ACCP it is easy to become overwhelmed with the potential of managing airway emergencies. Fortunately the DGH I work in embraces cognitive aids (intubation checklist, trache/laryngectomy emergency algorithms) and has provided equipment (standardised airway trolleys) as recommended by DAS. For me this removes a lot of anxiety associated with this kind of emergency situation. Furthermore, it ensures effective communication through the team by ensuring that we all have the same expectations and know what to do when things diverge from the norm.

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Our theatre department implemented the appropriate WHO guideline briefing checklist which has minimised any errors that could occur before and during an anaesthetic. The whole team communicates and has the opportunity to voice any concerns. This has made for a much safer environment with everyone on the same page for each and every patient.

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Noon-technical skills play a huge role in effectively and efficiently managing airways situations. Have clear designated leadership, which designates role and takes charge, and also allows for input from the team is key. Flattening the hierarchy and taking any member of the teams input into due consideration is important, as seen in the case with Elaine.

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I find the use of graded assertiveness to anectodally always be present in situations that are better controlled, with better outcomes. It keeps people accountable, minimises human factors that lead to error and improves overall communication and situational awareness

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This is very useful tool in CICO situation. The Vortex algorithm is easy to teach and memorize too. The assistant can easily bring to the notice of the operator what the next airway option is and prepare themselves to organize it.

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Team work, communication, situation awareness and decision making are important factors (human factors) to take into account, when doing a procedure specially during an attempt to intubate a patient in any scenario (ICU, ER or in the OR). Clinical skills are not the only factor that play a role during a procedure. All factors Technical and Non technial skills must be taken into consideration for a safe and secure airway management.

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I find that often in situations where a team is working together to reach a common goal, having someone who verbally takes everyone through the checklist or algorithm is really helpful to keep everyone on track

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It is a commendable tool, a way to look at airway safety, human factors, and ergonomics. However, this is not a widely used tool. Perhaps different organisations have different ways of recognising human factors. There should be more awareness of the ARACHNID airway spider tool.

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The Airway Spider is a reminder that it is not only clinical skills that Healthcare Professionals need to practice and be competent in, but Human Factors and Ergonomics are just as important as they are a major contributing factor to many adverse incidents that occur. As Healthcare Professionals we are guilty of forgetting about Human factors on occasions.

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During my university and working years, I have witnessed how bad is communication between health care professionals. Fuelled with ego and anger, during acute events I have witnessed fights and screams, which do not help at all during an emergency situation. After the emergency has passed, if the outcome was bad, the fighting resumed throwing the blame to each other. This behaviour does not allow reflection and much less resilience, we cannot learn from our mistakes if we can't accept we had them in the first place. I believe that as health professionals we need to be mentally and emotionally intelligent, and learn to communicate in an effective way trying to remain as calm as possible.

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Following the Arachnid process will ensure all staff engage in all steps of the spider and engage in the processes fully. There is a lot of information to read and this could perhaps be simplified to ensure individuals can remember all the sections required.

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The position the patient is located in a prehospital setting creates challenges especially depending on the amount of time that has passed in getting to patient. Getting enough equipment into appropriate positions to optimise success sometimes feels like it takes forever.

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I think it is imperative that we have standard ways of labelling and setting up our airway trolley in the Operating Theatre. Working across multiple departments and sites it is very apparent that there is often no method to the organisation of the trolley other than local practitioner preference. There is specific guidance for this from AAGBI and other areas which can be used to help standardise, locally we have tried to follow the Plan A,B,C.... approch so that even a practitioner that doesn't work in the area can quickly and effectively find the appropriate airway adjuncts and devices.

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Recently in our pre-hospital teams we have reintroduced intubation to certain Paramedics. As one of these clinicians who was previously used to working in a team where all Paramedics maintained the skill of intubation i have found that the wider team does not have full working of the algorithms which makes communicating the plan with the team under pressure harder, Training with a wider cohort than the staff that are carrying out the skill will build resistance and make use of the the non technical skills of the team. Using checklists with the whole team would improve this also

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During RSI, a common practice is to give preinduction drug followed by induction agent and then paralytic agent. Most times, even though drugs are labelled, they are not colour coded. Hence recognition from a distance is not possible. If paralytic is given first unknowingly, it can result in disastrous outcome. Hence colour coding is adviced. We use traffic light model. Green for pre-induction, yellow for induction and red for paralytic. This reduces the errors and helps in safety during airway management.

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Having the combinations with ARACHNID will ensure a more robust way of working from Training team and the individual worker to be more skilled and resilient.

Providing the tools and checklist reminds people simply the considerations required for optimised patient safety at the heart of our care.

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Culture is an underappreciated element in safety. A safety first culture allows team members to keep each other accountable, discourages deviation from standardised pathways and protocols, and enables us all to ask for help early.

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Using algorithms as a framework, before communicating your airway plan to your team - each member with well-defined roles, with equipment for each plan/step readily available, or at least if team members know where that equipment can be found rapidly

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Communication is key in these situations. Human factors will override knowledge and skills and has happened before. Having a checklist that staff can refer to can help to empower more junior staff to speak up.

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I think that addition of visual aids can assists massively in airway management. Often instances of airway management are chaotic and stressful and having a visual cue to bring you back to the situation and assist with logical thinking can be the key the success. The CICO algorithm is a great example of this. When things go wrong this algorithm provides a clear pathway in ensuring the best outcome for the patient in a life-threatening situation. It is very easy to become overwhelmed and 'foggy headed' during these critical times and having this very clear pathway is a huge advantage.

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Having roles within the team and knowing who is playing what role and their responsibilities are. Communication is vital to reduce the risk of HFE and for the team to work efficiently.

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During an elective list the consultant anaesthetist was great and let me talk through and lead every single ETT when I was PGY2. There was one patient who desaturated to 70% despite preoxygenation only seconds after taking the mask away to view the chords, which I could not see. I put the mask back on and looked at the anaestist and asked for him to take over, which he very calmly did. He made sure to discuss the patient after he intubated her. It was reassuring that he trusted my judgement and didn't push for me to keep trying as others have when I am worried.

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Having an open communication environment that allows the sharing of ideas from all members of the MDT is key in making sure all members feel confident to speak up when they feel something could be done differently or when there is a chance of harm if alternative management isn’t taken in to consideration. Equally pre discussing different anaesthetic plans should plan A not work to make sure everyone is aware of what to do if it isn’t a simple intubation.

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Effective team communication with clear case by case factors and sutuations discussed alongside a mandatory emergency procedure covered as Standard for every case. Departmental training days and simulation to support all staff to reognise and achieve these life saving protocols and precedures.

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Having algorithms clear and visible within the anaesthetic room allows for yourself and the team to refer to when in an emergency situation. It help prompt the next step to take i.e. "Call for help" etc. Also allowing for effective and clear communication between members of the team, which is essential to having a positive outcome.

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Relating to Algorithms and Checklists, having a standardised approach helps everyone involved stay on the same page about a situation. Ensuring this sort of structure is in place in any situations in which patients have an increased risk of harm can help the teams think about options or solutions, it can help them overcome barriers if they get stuck on an idea or thought as there is a clear next step ahead of them, and it means that if other people/teams/support arrive they can readily and easily join the team in troubleshooting and solving an issue.

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I find it useful when the anaesthetists let the rest of the team know if the patient has had any previous anaesthetics and if there were any problems with intubation or otherwise - we always keep bougies and stylets handy anyway, but it's useful to know if a patient is more likely than usual to require one.

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Clear team communication is essential - especially when there are unfamiliar members. Also important that basics such as equipment being fully charged and functioning; effective stock checking and storage of items in a standardised way all minimise delays in critical situations

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Human Error is inevitable, but this can be minimized by knowledge, design, right equipment's and an ideal setup. This is an example from the country I practice in. Rural areas as severely underfunded and understaffed, which is not an excuse but just a preface to the incident I am about to discuss. A 1 year infant was brought with seizures to ED in a rural hospital with only a single fresh medical graduate as the doctor. The doctor administered a benzodiazepine to control the seizure episode as they had learnt in medical school. The seizing subsided and it was then they remembered BZD causes respiratory depression and that the patient needed to be intubated. There was no facilities/ equipment for intubation and the junior doctor had never intubated a patient in the first place. The patient was referred out with a face mask and oxygen to the higher center with a nurse. The saturation was dropping and the nurse could only watch as the child died. This is a very serious error and one that could have been prevented, had the situation been handled with a guideline or checklist in mind. This would have prevented at the least, human error in this case.

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I always find the team briefs/huddles the most appropriate time to raise any airway management concerns and to start making plans for difficult airway management. As an anaesthetic nurse, I will always voice my concerns and make an A-D plan on the whiteboards situated in the theatres. I will also notify my circulating colleagues to make them aware that there is a possible difficult airway and that allows for extra assistance if needed. Making use of your colleagues and their knowledge means that you never have to face these cases alone. Speak up if youre uncomfortable. Advocate for both your patient and yourself. If making plans and writing them down makes you feel better and more organised then that is absolutely what you should do.

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I find when in emergency situations, its important to have a structure to fall back on when you are feeling stressed. In addition to helping you through the situation, it allows your team to be aware of where you are in the situation, meaning they can offer help.

Declaring where you are in a situation means that others can follow along with the algorithm too which is why I think this is such an important step.

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I think having a team leader who is able to have less of a hands on role and more of an overview of the situation is important - this goes hand in hand with situational awareness. That team leader can also give specific instructions directly to people so that there is no confusion in people's roles and actions to take.

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It's scarily easy to lose track of time or other things going around you when dealing with an emergency. One thing that stands out for me reading about the inquests mentioned is how the senior doctors did not realize the amount of precious time that had been lost to hypoxia. A member of the team should be nominated to "step back" and direct, keeping the big picture of regaining a well-ventilated and fully alert patient.

Communication should be well-directed and team members should be able to give constructive advice and suggestions.

Simulation training for crisis situation should also be regularly organized.

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During my experience as a foundation doctor on ITU. I was present during a cardiac arrest in a patient with a difficult airway. This patient initially had a LMA in place that was providing inadequate oxygenation. There were a lot of secretions and vomit. Attempts were made by the primary and secondary intubators to place an ETT tube without success. The decision to perform front of neck access was made. Whilst this equipment for this was being prepared there was no established airway. I felt at this time that the algorithm was not followed. I thought that the LMA should have been re-sited. despite it providing inadequate oxygenation as it was better that nothing at all, whilst front of neck access was established.

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I have always felt that simulation is not utilised enough within healthcare settings. This should involve everyone that is involved with the care of the patient throughout the anaesthetic stage. I have always found these so valuable as a learning experience and a way to try and add some normality to an emergency situation for all staff. Everyone plays a role and can add value to a complex situation.

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Impact of human factors on airway safety

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Impact of human factors on airway safety

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What resonates for me most in human factors is situational awareness and failure to recognise when an airway passes from routine to 'difficult', and from difficult to 'failed'. It can be easy to look in hindsight at actions taken in the face of airway emergencies and wonder why certain things were omitted, but often this comes down to lack of recognition of how serious the situation has become, and failure to communicate concerns within the team.

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having plans B, C, and D in place can significantly improve airway management by providing alternative airways, managing unexpected events, and reducing the risk of respiratory failure. By implementing these plans, healthcare providers can improve communication and collaboration, reduce confusion and errors, and ultimately provide better care for the patients.

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Communication is key to avoid unnecessary errors. Planning in advance your back-up options for intubation if plan A fails is a must. This should be communicated to the team/anaesthetic nurse at the brief to ensure all equipment is available and near by

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Breaking down barriers to raising concerns - Resilience

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Breaking down barriers to raising concerns - Resilience

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After potentially traumatic events in my emergency department, staff are invited to a debrief with the senior clinicians and health care professionals involved. It offers an opportunity for the team to reflect on and discuss the events thereby improving their resilience to deal with difficult, stressful situations in the future.

Also ensuring introductions take place at the beginning of a procedure and attempting to use language which breaks down hierarchy thereby allowing more junior or less confident members of the team to raise concerns and feel important is vital for enacting the non-technical skills in a team e.g. good communication, reducing stress, establishing competency levels.

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C= CHECKLIST

Checklist plays important role, I used to work in ICU/HDU.

We got this tracheostomy patient which is difficult to manage his

secretions. ARACHNID was introduced one of them is CHECKLIST,

4 hourly check was included (suctioning, inner tracheostomy etc)

to improve patient airway. Since, then looking after tracheostomy

patient is proven to improve, patient safety.

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I think guidelines, algorithms and policies and procedures are formulated to work the safest possible. But sometimes even how clear the algorithms and guidelines are. We humans won't just let go and accept that we failed and will have to go to the left side of the algorithm or proceed to next step.

As a nurse who have been working in critical care for 14 years, I also have witnessed several times that its the culture in our profession that sometimes makes it difficult to get the job done. In airway management, especially in a critical and life-saving situation, we should work collectively and respectfully with each other.

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Responding to feedback - patient or colleague

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Responding to feedback - patient or colleague

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I have only recently joined the ICU and I have already witnessed some brilliant team work and great communication. Trainee anaesthetist and trainee ACCP intubating a patient with rapidly falling saturations. It wasn't a perfect intubation but it was successful and we had a great team debrief. Communication is integral to this success. The checklist being read out by someone familiar with the process and who knows the equipment is so important.

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I was recently involved in what appeared to be a difficult intubation. A checklist was followed with the person reading out the checklist also taking on the role of a leader. The primary intubater was clearly finding the intubation difficult, the leader recognized this immediately and intubator 2 undertook the intubation successfully. This just highlighted the risks of becoming task focused and the importance of a lead and a checklist when carrying providing airway management.

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Awareness of HFE in difficult airways and other emergencies will underpin the solutions and systems going forward. One way is to have regular team training and debriefs to both target human factors and non-technical skills in the error chain.