McGrath B et al. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia 2012;67:1025–1041.
NCEPOD. On the Right Trach? A Review of the Care Received by Patients who Underwent a Tracheostomy. London: NCEPOD; 2014 (https://www.ncepod.org.uk/2014report1/downloads/OnTheRightTrach_FullReport.pdf).
Faculty of Intensive Care Medicine and Intensive Care Society. Invasive Procedure Safety Checklist: Tracheostomy. London: Faculty of Intensive Care Medicine; 2019 (https://www.ficm.ac.uk/safety-and-clinical-quality/safety-checklists-invasive-procedures).
Intensive Care Society. Standards for the Care of Adult Patients with a Temporary Tracheostomy; Standards and Guidelines. London: ICS; 2014 (https://www.ics.ac.uk/ICS/ICS/GuidelinesAndStandards/ICSGuidelines.aspx).
Thomas, AN, McGrath, BA. Patient safety incidents associated with airway devices in critical care: a review of reports to the UK national patient safety agency. Anaesthesia 2009;64:358–365.
McGrath, BA, Thomas, AN. Patient safety incidents associated with tracheostomies occurring in hospital wards: a review of reports to the UK national patient safety agency. Postgrad Med J 2010;86:522–525.
Institute for Healthcare Improvement. How to improve (http://www.ihi. org/resources/Pages/HowtoImprove/default.aspx).