Reducing the Morbidity Associated With Incorrect Pediatric Tracheostomy Tube Placement: A Quality Improvement Initiative

Increased access to accurate TT information in the EMR demonstrated an increased interval between events. Future work includes routinely tracking events as a new metric to follow and implementing other interventions from the KDD for a multi-interventional approach to the global aim. We recommend that organizations implement this straightforward approach to dramatically reduce untoward outcomes with catastrophic potential.