First reported 17 Nov 2017•Latest report 13 Jun 2024
Definition
What this concern includes
Includes failures of the capnography safety process during intubation or resuscitation, including dissemination and understanding of relevant guidance, availability, correct use, and assurance that clinical staff who may intubate use capnography appropriately.
Not included
Excludes generic clinical training, guidance dissemination or monitoring deficiencies without a direct capnography connection.
Excludes failures involving airway management, intubation or resuscitation where capnography is not the deficient control.
Excludes failures occurring after capnography has been reliably used, including unrelated treatment or escalation failures.
Excludes capnography concerns outside intubation or resuscitation unless they explicitly support the same bounded capnography safety process.
Reports
4
Distinct published reports
Individual concerns
6
A report can raise multiple concerns
Date range
2017–2024
First to latest report issue date
Stated actions
12
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Royal College of Anaesthetists3
Department of Health and Social Care2
NHS England2
Difficult Airway Society1
Faculty of Intensive Care Medicine1
Milton Keynes University Hospital1
North Cumbria Integrated Care NHS Foundation Trust1
North West Anglia NHS Foundation Trust1
Royal College of Emergency Medicine1
Health professional body3
Executive non-departmental public body2
Ministerial department2
NHS trust2
Healthcare site1
Registered charity1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Avon
Concerns raised1
Failure to endorse and disseminate PUMA airway management guidance
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Disseminate key PUMA guideline messages to members through safety communications and events.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Faculty of Intensive Care Medicine and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Some concerns about PUMA guideline endorsement and dissemination fall outside NHS England’s national policy or programme remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Royal Colleges are better placed to respond to concerns outside NHS England’s national policy or programme remit.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Milton Keynes
Concerns raised1
Lack of awareness of the capnography safety campaign among anaesthesia staff
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Disseminate key lessons through Royal College, Association and Difficult Airway Society journals, newsletters and social media.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 9 September 2021.
Action
Present key lessons at specified anaesthesia, airway and perioperative educational conferences and meetings.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 9 September 2021.
Action
Work with operating department and perioperative stakeholders to ensure key messages reach the whole theatre team.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 9 September 2021.
Action
Work with other Royal Colleges to share key messages with all medical professionals undertaking intubation.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 9 September 2021.
Action
Publish and promote the “Capnography in Cardiac Arrest: No Trace = Wrong Place” video through professional communication channels.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated completedThe respondent said that this action was complete when they made their response on 9 September 2021.
Action
Continue disseminating key lessons on preventing unrecognised oesophageal intubation through webpages, talks, publications, online resources and social media.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated in progressThe respondent said that this action was in progress when they made their response on 9 September 2021.
Cumbria
Concerns raised1
Lack of understanding of capnography interpretation during CPR
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Cambridgeshire and Peterborough
Concerns raised3
Failure to ensure sufficient understanding of capnography among clinical staff who may intubate patients
Failure to ensure utilisation of capnography by clinical staff who may intubate patients
Failure to observe capnography for up to 15 to 20 seconds after intubation
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Deliver high-fidelity airway simulation training covering capnography, technical airway skills, human factors and crisis-management skills to all Hinchingbrooke anaesthetic staff.
Stated by North West Anglia NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 February 2018.
Action
Publish and circulate safety information on exhaled carbon dioxide during resuscitation through anaesthesia newsletters and Patient Safety Update.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 15 February 2018.
Action
Present the exhaled-carbon-dioxide issue to national Airway Leads and invite feedback on improving training.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 15 February 2018.
Action
Ask e-Learning for Anaesthesia providers to consider highlighting exhaled carbon dioxide in intubation, capnography and resuscitation sessions.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 15 February 2018.
Action
Work with the AAGBI to promote regular multidisciplinary crisis simulation through its forthcoming emergency-management handbook.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Difficult Airway Society and Royal College of AnaesthetistsStated in progressThe respondent said that this action was in progress when they made their response on 15 February 2018.
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Includes failures of the capnography safety process during intubation or resuscitation, including dissemination and understanding of relevant guidance, availability, correct use, and assurance that clinical staff who may intubate use capnography appropriately.
