Patient Safety Topics

Airway management, specifically ensuring uninterrupted oxygenation and ventilation, is a fundamental part of the practice of anesthesia and of emergency and critical care medicine. Poor outcomes can be avoided by implementing a comprehensive approach that includes thorough patient evaluation, multidisciplinary cooperation with a predetermined airway management strategy, skillful use of standardized equipment, frequent staff education, dissemination of important patient information, and a willingness to ask for assistance.

Key Data and Statistics

In 2009, the Authority received 448 event reports involving complications related to anesthesia. Of these reports, 36 involved a difficult intubation. Six events were reported as an anticipated difficult airway involving patients with the following risk factors:

  • Known history of difficult intubation (two patients)
  • Anterior larynx (one patient)
  • Small mouth (one patient)
  • Kyphosis resulting in difficult positioning(one patient)
  • Severe neck swelling due to bleeding (one patient)

For 23 events, difficult intubation was reported as unanticipated. In the seven remaining reports, it was indeterminable whether the difficult intubation was anticipated. Nine events involving a difficult intubation resulted in harm to the patient.

Reports of difficult intubation in which the patient was harmed include the following:

Intubation took three attempts. The larynx was anterior and made for difficult intubation. The patient had difficulty swallowing postoperatively and was found to have an esophageal perforation.

The anesthesiologist was attempting to insert the [endotracheal] tube using a GlideScope®. The patient's mouth was small, and the size of the tube prevented direct visual placement. Several attempts were made; then, copious amounts of blood were noted in the oropharynx. A laceration of the tonsil occurred.

A patient was admitted for shoulder surgery under general anesthesia. [It was a] difficult intubation. During intubation, an approximate 1 cm laceration of the soft palate occurred.

Excerpted from: Management of unanticipated difficult intubation. Pa Patient Saf Advis 2010 Dec.

Educational Tools

​Difficult Airway Alert Form
This sample form may be used to inform subsequent providers about a potential difficult airway and can be modified per facility policy and procedure.


Visit this section in the future for any multimedia associated with this patient safety topic.



Safety Tips for Patients