Tracheostomy and Laryngectomy Airway Safety Events: An Analysis of Patient Safety Reports From 84 Hospitals


  • Lea Anne Gardner, PhD, RN Patient Safety Authority
  • Rebecca Jones, MBA, RN Patient Safety Authority
  • Christopher H. Rassekh, MD Penn Medicine
  • Joshua H. Atkins, MD, PhD Penn Medicine



tracheostomy, patient safety, laryngectomy, unplanned decannulation


Visual Abstract

Background: Tracheostomy- and laryngectomy-related airway safety events can lead to life-threatening situations, permanent harm, or death. We conducted a statewide population-based study to learn about these events and the relationship with associated factors, interventions, and outcomes to identify potential areas for improvement.

Methods: We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) to find tracheostomy- and laryngectomy-related airway safety event reports involving adults age 18 years and older that occurred between January 1, 2018, and December 31, 2020.

Results: Reports related to tracheostomies and laryngectomies accounted for 97.3% and 2.7% of the total, respectively. The four most frequent tracheostomy-related complications were unplanned decannulations, 71.4%; uncontrolled bleeding/hemorrhage, 9.2%; and partial/total occlusion and mucus plug/thick secretions, which each accounted for 6.9%.

Conclusions: Safe airway management for patients with a tracheostomy or laryngectomy requires staff who are knowledgeable and confident, and have the necessary skills and equipment to provide immediate attention when complications arise. We discuss potential safety strategies to reduce the risk of unplanned decannulations, uncontrolled bleeding/hemorrhage, and partial/total occlusions, as well as issues related to equipment, knowledge/training, and communication.

Author Biographies

Lea Anne Gardner, PhD, RN, Patient Safety Authority

Lea Anne Gardner ( is a patient safety analyst with the Patient Safety Authority. She has more than 30 years of research experience in patient safety, performance improvement, cardiology, and behavioral health. She has served as a national director of nursing, quality improvement, and population health, and an administrative director of an institutional review board. Gardner is also a Certified Professional in Patient Safety (CPPS).

Rebecca Jones, MBA, RN, Patient Safety Authority

Rebecca Jones is director of Data Science and Research at the Patient Safety Authority, where she also founded and serves as director of the Center of Excellence for Improving Diagnosis. Her previous roles at the PSA include director of Innovation and Strategic Partnerships, and regional patient safety liaison. Before joining the PSA, Jones served in various roles leading patient safety efforts and proactively managing risk in healthcare organizations. She currently is chair of the Practice Committee of the Society to Improve Diagnosis in Medicine and serves on the Advisory Committee of the Coalition to Improve Diagnosis.

Christopher H. Rassekh, MD, Penn Medicine

Christopher H. Rassekh is a professor of clinical otorhinolaryngology: head and neck surgery at the Hospital of the University of Pennsylvania. He is a head and neck surgical oncologist and is a co-chair of the Penn Airway Safety committee. He is also director of Risk Reduction and director of Professional Practice at the Department of Otorhinolaryngology — Head and Neck Surgery, and director of the Penn Medicine Salivary Gland Center.

Joshua H. Atkins, MD, PhD, Penn Medicine

Joshua Atkins is associate professor of Anesthesiology and Critical Care, and director of Anesthesia for Head and Neck Surgery at the Perelman School of Medicine at the University of Pennsylvania. He is co-chair of the Penn Medicine System Airway Safety Committee, serves on the editorial board of Patient Safety, directs the perioperative team simulation program at the Hospital of the University of Pennsylvania, and is a TeamSTEPPS educator. Dr. Atkins is currently partnering with industry on the development of novel technologies for anesthesia medication safety.


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How to Cite

Gardner, L. A., Jones, R. ., Rassekh, C. H., & Atkins, . J. H. (2022). Tracheostomy and Laryngectomy Airway Safety Events: An Analysis of Patient Safety Reports From 84 Hospitals. Patient Safety, 4(1), 26–39.



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