KeypointsNumerous studies have demonstrated the significant morbidity and mortality attributable to tracheostomy‐related patient safety incidents in the paediatric population.We have introduced a multidisciplinary tracheostomy care improvement programme across our tertiary paediatric hospital including application of the Paediatric National Tracheostomy Safety Project emergency guidelines over a 6 year period.Our retrospective review of 128 tracheostomy‐related patient safety incidents during this period has demonstrated rapid and sustained trend in reduction in harm from 57% to 26% (P = .013).Reduction in harm likely represents better recognition of appropriate long‐term and emergency management, followed by appropriate guided responses by trained staff.Future research should be directed towards observing if this sustained harm reduction is reproducible at other institutions.INTRODUCTIONIn the UK, patient safety issues related to adult tracheostomies are well recognised. A number of reports from the National Patient Safety Agency and National Confidential Enquiry into Patient Outcome and Death highlighted recurrent themes with deficiencies in staff education, resources, equipment provision and emergency guidance.Similar patient safety concerns exist in the paediatric population. Studies report overall mortality rates in paediatric patients with tracheostomies varying from 2.2% to 58.8%, whilst tracheostomy‐specific mortality is lower at 0.9% to 5.9%. Within our institution, concerns were noted regarding the risk of
Clinical Otolaryngology – Wiley
Published: Jan 1, 2018
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