Fish bone analysis
| People | Place | Process | Policy |
| Nurses not well trained about drugs preparation | No proper designated place for intubation equipment and drugs tray | Absence of airway drug checklist | No standardised induction agents policy |
| Resident doctors inexperienced in RSI | Space constraints to bring resuscitation trolley to bed side of patient | Lack of departmental policy on difficult airway management | |
| Communication gap between doctors and nurses | Overcrowded resuscitation area and emergency room | ||
| Insufficient nursing staff in resuscitation area |
RSI, rapid sequence intubation.