Failed intubation: anaesthesia's Achilles' heel.

A report on participant views of a two-person check confirming tracheal intubation implemented in their institution found that this check was generally considered feasible and useful, but there was some resistance and some concerns that it would not solve the problem.

Social, cultural, and cognitive factors play a role in airway management in the operating theatre, partly because of the pre-eminence of airway management as a cornerstone of the profession of anaesthesia. These factors contribute to loss of situation awareness in airway failure.

Although situation awareness might be better maintained by the two-person check, there could be advantages if airway management became the responsibility of the whole operating theatre team.

Potential strategies to overcoming the ongoing problem of failed airway management are proposed, including multidisciplinary team training in airway management and a new airway point in the surgical safety checklist time out.