Spotlight on Unplanned Extubation : Drew’s Story

By Dr. Art Kanowitz

Unplanned extubation (UE) — the unplanned, uncontrolled removal of a patient’s life-sustaining breathing tube –– is an all-too-common patient safety issue. In fact, it occurs in more than 200,000 adult and neonatal ICU patients in the U.S. alone, resulting in 50,000 deaths. These are preventable deaths and as such, have become an important part of the PSMF mission.

During the summer of 2013, 13-year-old Drew Hughes was skateboarding with his friends as he had many evenings in the past. But this evening was different, Drew fell and hit his head. He was taken by ambulance to the hospital emergency room where he appeared awake and alert. However, a CT scan showed evidence of a possible basilar skull fracture. To be sure that was the case, Drew was transferred to a Level 1 trauma center. Tragically, he didn’t survive the transport.

In the ambulance, his life-sustaining breathing tube was accidentally removed and not replaced properly. Drew’s oxygen levels dropped, and his heart rate slowed. By the time the team diverted to a nearby hospital, it was too late. Drew suffered anoxic brain injury and lost his life.

The Patient Safety Movement Foundation recently joined 18 medical and patient safety and quality improvement organizations to form the Coalition for Unplanned Extubation Awareness and Prevention. The coalition’s collective goal is to raise awareness about UE and work with hospitals to implement standardized policies and procedures, and to begin tracking and implementing quality measures. Drew’s father David Hughes, serves as the co-chair of the PSMF’s Airway Safety Workgroup, which works closely with the coalition. The Do It for Drew Foundation, headed by Hughes, is part of the coalition.

Improving UE-related events and patient safety requires a collaborative effort from patient safety leaders, hospital executives, providers, medical technology companies, and patients. To learn more about how you can help, what’s being done, and Drew’s story, read this blog published by the Airway Safety Movement.