Individual meets unfortunate demise due to medical error, with breathing tube accidently placed in the food pipe.
In a tragic turn of events, a 73-year-old woman lost her life during an operation at an Auckland hospital in 2021. The cause of death was a breathing tube being mistakenly placed in her food pipe instead of her windpipe, a complication known as oesophageal intubation.
The lead anaesthetist, Dr C, stated that multiple factors combined to create an extremely confusing crisis. Dr C had dealt with multiple food pipe intubations over the years, but all had been diagnosed and rectified quickly, according to his statement. However, in this case, the error was not found until after the woman's heartbeat and oxygen level dropped during surgery, leading the operating team to perform CPR.
The deputy commissioner, Carolyn Cooper, criticised Dr C for not responding quickly enough to concerns that the tube was in the wrong place, and for not taking a hands-off leadership role during the crisis. Dr C did not follow the crisis checklist, a list on the wall of the theatre with a step-by-step guide to use when something goes seriously wrong, according to the deputy commissioner's report.
The junior doctor who inserted the tube asked to redo it several times in case it was not in properly, but Dr C refused due to concerns about maintaining the woman's airway. Measurements and observations initially appeared to show the tube was in the right place, but it became apparent something was wrong.
The woman's complex case was due to her high body mass index of 44, previous cancers, a nodule in her lung, and serious complications with ventilation in an earlier operation. These factors likely contributed to the confusion and the difficulty in diagnosing the error.
Health NZ viewed the oesophageal intubation complication as a system-based problem, not the failing of an individual. Cooper, the deputy commissioner, also criticised Health NZ, Auckland, for systemic problems including a lack of leadership and a lack of teamwork.
Since the incident, Health NZ in Auckland has implemented stricter airway management protocols, enhanced staff training, and introduced more rigorous patient safety checks to prevent such incidents. They have also made changes, including educating staff about the case.
Dr C, the lead anaesthetist, stated that there was an "overwhelming expectation of bronchospasm" due to the woman's past history. He has since changed his practice and undergone further training on airway emergencies.
The Health and Disability Commissioner (HDC) has criticised both Dr C and Health NZ, Auckland, for the incident. Unrecognised oesophageal intubation is a very rare problem, likely occurring in one in a million anaesthetic treatments, according to Health NZ.
In this incident, an emergency bell was rung, and at one stage, there were up to 20 people in the operating theatre. This highlights the urgency and gravity of the situation. The woman's death serves as a stark reminder of the importance of adhering to protocols and the need for effective teamwork and leadership in the medical field.
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