Unplanned extubation (UE) is the unintentional removal of a patient’s life-sustaining breathing tube which occurs when a patient removes their tube (self-extubation) or when the tube is dislodged by an external force (accidental extubation). It can also occur when the endotracheal tube malfunctions (i.e. balloon failure) requiring replacement of the tube (device malfunction). While preventable with stepwise, simple measures, UE is a major cause of harm and death both in the hospital and in the emergency medical service (EMS) sector. Of the 1.65 million intubated ICU patients in the US annually, 121,000 are estimated to experience unplanned extubation (da Silva & Fonseca, 2012).

Our APSS outline actionable steps healthcare organizations should take to successfully implement and sustain behavior change for high reliability, shared understanding, thorough communication, and meaningful person-centered care across the organization.

Actionable steps include:

• Executive Summary Checklist
• Leadership checklist guide to determine whether current evidence-based guidelines are being followed in your organization
• Performance improvement plan to follow if improvements are necessary
• Clinical workflow for preoccupation with workflow for areas of improvement
• How to educate patients and family members about the significance of their role throughout the continuum
• Guidance on how to measure outcomes