| Document
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Author Melody CheN, B. L. William Wong |
| Abstract Unrecognised oesophageal intubation (UOI) is a medical procedural error in which a breathing tube is mistakenly placed into the oesophagus and not promptly identified or addressed. A literature review on the human factors relating to UOI was performed and findings presented in the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Key themes relating to issues around intubation equipment factors were used to inform the design of a cognitive aid to improve human performance in this clinical context. A semantically meaningful tray consisting of images and uniquely sized slots was created and sought to address technical and non-technical human factors identified in adverse event reports and coronial cases of UOI. |
