Unplanned Extubation
Common. Costly. Deadly.

Unplanned Extubtion is making headlines for all the wrong reasons. Read about the real UE cases and its affect on hospitals and individuals across the country.

 

A tragic breathing tube dislodgement story

According to the lawsuit, Bentley was admitted to the intensive care unit after suffering a traumatic brain injury. As a patient, he relied on a tracheostomy tube for oxygen. 

On April 20, 2017, sometime around 2:30 a.m., Bentley’s breathing tube became dislodged, the suit said. When the problem was discovered, the complaint said, attendants “could not immediately replace the … tube and could not immediately restore the significant oxygen flow. 

“As a result of the disrupted flow of oxygen … he suffered cardiac and respiratory distress which resulted in anoxic brain injury with severe anoxia.

Read the full article from the Roanoke Times

Wrongful death suit due to UE

Community Memorial Hospital staff didn’t respond quickly enough when a dislodged breathing tube cut off a patient’s oxygen supply, a wrongful death lawsuit alleges.

Family members of Rafael Guillen said in the lawsuit that the 44-year-old Oxnard man who used a ventilator to breathe was left without oxygen for at least 30 minutes before staff at the Ventura hospital discovered what happened. He suffered massive brain damage and died several days later on May 5, 2018, according to litigation filed against the Community Memorial Health system in March in Ventura County Superior Court.

Read the full article on VCStar.com

Death and lawsuit from UE

According to the complaint, Robert Pine alleges that on Dec. 5, 2016, the defendants provided anesthesia to Sharon Pine for a lithotripsy procedure, a treatment typically using ultrasound shock waves. As a result of the defendants' negligent acts and omissions, she became unresponsive and her pupils were fixed and dilated. She died on Dec. 8, 2015, after suffering from anoxic brain injury. Robert Pine suffered the loss of comfort, society and service of his wife.

Read the full article from West Virginia Record

UE death in a baby

An investigation into one of the UK's top children's hospitals has begun after a three-month-old baby died.

Aksharan Sivaruban was due to have routine surgery to treat a hernia at Evelin London Children's Hospital but allegedly suffocated while in the hospital.

A breathing tube had become 'displaced' after being placed in the infant's throat before he died from a cardiac arrest on December 12.

A team of 16 staff tried for 45 minutes to resuscitate the boy but were unsuccessful.

Read the full article from the Daily Mail UK

Another tragic story of a UE death in a baby

A premature newborn baby died days after his twin brother when hospital staff 'missed opportunities' to recognize a vital ventilation tube had been dislodged, an inquest heard.

Read the full article from the Manchester Evening News

Rattlesnake bite story with UE

"(If) that endotracheal tube would come out, because of severe neck swelling, it would be difficult or impossible to immediately put it back in or immediately perform ... an emergency tracheotomy," Curry said. "Because if that tube were to come out, then we would expect that they would be in very big trouble immediately, and perhaps might even die in four to five minutes."

Read the full article from AZCentral.com

Lawsuit and death from UE

The family of a 29-year-old mother of two from Burleson, Texas, has filed a medical negligence lawsuit against Medical Center Arlington, the same hospital where the woman had worked as a surgical technician for eight years. The lawsuit says the victim was deprived of oxygen for more than a half-hour and suffered permanent brain damage when her breathing tube was dislodged.

Read the full article from the Digital Journal

Lawsuit from UE

However, Albear did not secure the tube properly, Pavalon said. When the tube became dislodged, Albear was unable to reinsert it, depriving Morkos of oxygen.

By the time surgeons were able to perform an emergency tracheostomy to provide oxygen to Morkos, 10 to 12 minutes had passed. She then went into cardiac arrest.

"There was no doubt that the negligence in this case caused this tragic occurrence and Neveen's irreversible brain damage," said Pavalon, a lawyer with the Chicago firm Pavalon, Gifford, Laatsch & Marino. "So not only do the circumstances justify this record settlement, but this is one of those traumatic occurrences that simply should not have happened."

After the incident, Morkos initially was in a vegetative state, but she has improved. Though she requires round-the-clock care and cannot walk, she can now say her husband's name and recognizes her children, Halana, 6, and Victor, 3, Pavalon said. She also can write in Arabic.

Read the full article from the Chicago Tribune

Efforts against UE

We’re inspired by the work being done across the industry to stop UE in its tracks.

 

Solving the UE problem

Tricia Cady used to lie in bed awake thinking about babies in her neonatal intensive care ward. NICU babies frequently pull out their breathing tubes and lines, and Cady said she would run over ideas for keeping unplanned extubations at bay.

“It’s nerve-wracking as a nurse because you can’t just sit at their bedside all day and wait,” she said. “So if we can’t do that, what can we do?”

Read the full article from the Roanoke Times

Data and observations regarding UE in the NICU.  A must read.

Each year, more than 800 medically fragile newborns are transferred to Children’s 60-bed NICU from dozens of regional hospitals, often within hours of birth. Many of these infants are born so premature their lungs have not had time to fully develop, requiring mechanical ventilation via an endotracheal tube to keep them alive. Unintended extubations (UE) – when such breathing tubes accidentally become dislodged – are the fourth-most common adverse event in the nation’s NICUs and can lead to airway trauma, bleeding and cardiovascular collapse. 

Read the full article from Children’s National

A hospital is lobbying for safer nurse to patient ratios – citing UE as a risk point

The issue of patient overload facing hospitals in Pennsylvania is not just a matter of overwhelming nurses, it's bad for patients too. 

Joanna Haneman, a nurse from Homestead, lays out this hypothetical: A nurse has multiple very needy patients, but can’t treat all of them at once. This forces the nurse to triage the situation. The nurse decides to handle the most pressing patient needs, like someone's breathing tube becomes dislodged. Then another patient's heart rate starts to spike. Those patients are taken care off, but those responsibilities have left a patient who has soiled themselves unattended to for 30 minutes.

Read the full article from Pittsburgh City Paper

Developing solutions for UE in babies and children

This year, participants in the Institute for Pediatric Innovation’s (IPI) Clinical Innovation Catalyst program focused on finding product improvements that could reduce the occurrence of unplanned extubations (UEs).

Read the full article on PRWeb.com

The rising tide that lifts all boats

One of the most important, yet stressful jobs clinicians do is to ensure critical, life-sustaining tubes are safely secured because even the slightest millimeter of movement can be life-threatening for some patients. While recent adhesive advances have incrementally improved critical tube securement performance, clinicians are still facing challenges to safe securement under hard-to-adhere-to conditions like diaphoretic skin, saliva and humidity. To fill this clinician need, 3M developed 3MTMDuraporeTM Advanced Surgical Tape, a high-adhesion medical tape designed to provide safe, reliable critical tube securement in challenging conditions like high-moisture environments.

Read the full article from Business Insider

 
 
 

The Solution

 

Our patented airway stabilization system is designed to eliminate complications of Unplanned Extubation.

 
 
 
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