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:
APSS are revised annually and available free of charge on our website for download.
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