Profiles in patient safety: organizational barriers to patient safety.

A 46-year-old woman presented to the trauma unit with a history of being trapped in a house fire. The trauma team, composed of a trauma surgery (TS) attending, an emergency medicine (EM) attending, four EM and surgery residents, and two trauma nurses, met the patient at arrival. The patient had a Glasgow Coma Scale (GCS) score of 15 and complained of shortness of breath, severe eye pain, and hoarseness. There were no burns to her skin. Past medical history was significant for coronary artery disease with multivessel bypass six years prior. Physical examination supported the history of heavy smoke and thermal inhalation. Advanced Trauma Life Support (ATLS) protocols were instituted. An arterial blood gas (ABG) upon arrival demonstrated a carbon monoxide (CO) level of 28%. Both attendings agreed that urgent intubation was indicated. The procedure changed from an urgent to an emergent procedure when the nurse administered the paralytic agent first and prior to the setup of intubation materials. Although finally successful, the procedure was further complicated by gross edema of the epiglottis from thermal injury causing obstruction of the airway and a disagreement between the EM and trauma attendings about whether to perform a