Three safety events involving bedside tracheostomy (trach) changes—downsizing and occasionally upsizing—occurred at a hospital in one year, one of which was self-reported by a respiratory therapist to the respiratory manager. In response, the respiratory manager met with the patient safety manager and initiated a review with the respiratory staff. Through this review, they learned that there was no consistent practice for changing trachs and every staff member performed the procedure differently. They also identified other issues: there was no clear place for physicians to order a trach change, and sometimes no order was placed. These findings resulted in process improvements, which included a time-out procedure before a trach is changed, performed by two clinicians (a registered nurse (RN), another respiratory staff member, or a physician) and confirming the correct patient, correct trach and size, and presence of a physician order in the chart. A huddle sheet created for education was provided to the RN, physician, and respiratory staff; a policy was created to outline procedures for trach changes; and sections were added to the physician order for specific information related to the trach change, such as trach type and size. The time-out is documented in the patient’s medical record and the respiratory manager frequently reviews the data to ensure compliance. No events related to this error have been documented since the new procedures were implemented.​

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