Table 1

Fish bone analysis

Nurses not well trained about drugs preparationNo proper designated place for intubation equipment and drugs trayAbsence of airway drug checklistNo standardised induction agents policy
Resident doctors inexperienced in RSISpace constraints to bring resuscitation trolley to bed side of patientLack of departmental policy on difficult airway management
Communication gap between doctors and nursesOvercrowded resuscitation area and emergency room
Insufficient nursing staff in resuscitation area
  • RSI, rapid sequence intubation.