Who is responsible when an intubated (intubation) patient in a prone position experiences tube dislodgement leading to cardiac arrest?

Who Is Responsible for Endotracheal Tube Dislodgement During Prone Positioning Leading to Cardiac Arrest?

The entire medical team shares collective responsibility for this catastrophic outcome, with primary accountability resting on the physician supervising the prone positioning procedure and the bedside nurse directly managing the airway, as both failed to implement mandatory safety protocols for tube verification during patient repositioning.

Established Standard of Care Requirements

The medical literature unequivocally establishes that endotracheal tube position must be confirmed each time a patient is moved, including during prone positioning 1. This is a Class I recommendation with Level of Evidence B, meaning it represents a standard of care that must be followed 1.

Specific Monitoring Requirements During Patient Movement

• Tube depth must be monitored and recorded at every shift and specifically checked both before and after repositioning procedures 1
• Cuff pressure must be checked and corrected both before and after prone positioning to prevent displacement 1
• Waveform capnography is mandatory to immediately detect tube displacement and must be continuously monitored during any patient movement 1
• The British Journal of Anaesthesia explicitly states that tube displacement is a recognized risk during prone positioning and requires systematic preventive measures 1

Distribution of Responsibility

Primary Clinical Responsibility

The supervising physician bears primary responsibility for:

• Ensuring adequate staffing and trained personnel are present during prone positioning 1
• Verifying that monitoring equipment (especially capnography) is functional and in place 1
• Establishing and enforcing protocols for tube verification before, during, and after repositioning 1

The bedside nurse or respiratory therapist managing the airway bears direct responsibility for:

• Physically securing the tube and monitoring its depth marking 1
• Continuously observing capnography waveforms during the turn 1
• Immediately alerting the team to any loss of capnography signal 1

Institutional and Systems Responsibility

The healthcare institution shares responsibility through:

• Failure to implement mandatory protocols for high-risk procedures like prone positioning 1
• Inadequate training of staff on airway management during patient repositioning 1
• Absence of required monitoring equipment (capnography) at the bedside 1

Critical Failures in This Case

Immediate Detection Failure

The absence of immediate recognition indicates capnography was either not in use or not being monitored 1. The 2018 British Journal of Anaesthesia guidelines state it is "mandatory to use waveform capnography" and that "absence of a recognizable waveform trace indicates failed intubation unless proven otherwise" 1.

• Tube dislodgement during prone positioning should be detected within seconds if capnography is properly monitored 2
• The progression to cardiac arrest indicates a prolonged period of unrecognized esophageal intubation or complete extubation 1

Protocol Violation

The American Heart Association explicitly lists the mnemonic DOPE (Displacement, Obstruction, Pneumothorax, Equipment failure) as the systematic approach when an intubated patient deteriorates 1. Tube displacement is the first consideration and must be immediately evaluated 1.

Legal and Professional Accountability Framework

Standard of Care Breach

This represents a clear breach of established standard of care because:

• Multiple published guidelines from major societies (American Heart Association, British Journal of Anaesthesia, Intensive Care Medicine) explicitly require tube position verification during patient movement 1
• The 2010 AHA guidelines classify this as Class I evidence (should be performed) 1
• Prone positioning is a known high-risk procedure for tube dislodgement, explicitly mentioned in sepsis management guidelines 1

Shared Liability Model

In most jurisdictions, this scenario would result in shared liability:

• The attending physician for inadequate supervision and failure to ensure proper monitoring protocols
• The bedside clinicians for failure to detect and respond to tube dislodgement
• The institution for systems failures in protocol implementation and staff training
• Potentially the respiratory therapy department if they were responsible for airway management during the procedure

Prevention Requirements Going Forward

Mandatory Safety Checklist for Prone Positioning

Before any prone positioning of intubated patients 1:

• Ensure adequate sedation and consider neuromuscular blockade 1
• Verify capnography is functioning and continuously displayed 1
• Document baseline tube depth at the teeth/lips 1
• Check and document cuff pressure (should be 20-30 cm H₂O, or at least 5 cm H₂O above peak inspiratory pressure) 1, 3
• Assign one team member specifically responsible for airway management 1

During the turn 1:

• Pause ventilator and clamp tube if disconnection is required 1
• Maintain continuous visualization of tube depth marking 1
• Monitor capnography waveform continuously 1

Immediately after repositioning 1:

• Reconfirm tube depth and document any change 1
• Recheck cuff pressure 1
• Verify bilateral breath sounds 1
• Confirm sustained capnography waveform 1

Common Pitfalls That Likely Occurred Here

• Relying on pulse oximetry alone: Oximetry may not decline for up to 3 minutes after loss of ventilation, especially if the patient was well pre-oxygenated 1
• Assuming tube security: Even well-secured tubes can dislodge during major position changes 1
• Inadequate staffing: Prone positioning requires sufficient personnel to safely manage the airway while turning 1
• Failure to use capnography: This is the single most reliable method for immediate detection of tube displacement 1, 2

The progression to cardiac arrest was entirely preventable with adherence to established monitoring protocols 1.