Notes from a Small Island: Lessons from the UK NCEPOD Tracheotomy Report.

The spotlight in the care of tracheotomy patients has turned in recent years onto multidisciplinary care, scrutinizing the patient journey from initial treatment decisions through tracheotomy to postprocedural care. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) conducted a national study into tracheostomy care in the United Kingdom, reporting the most comprehensive analysis of in-patient care to date. Key findings highlight recurrent deficiencies in the organization of care, staff training, and support and the inconsistent use of monitoring and safety equipment. The NCEPOD study findings are translatable to Western health care systems and serve to highlight important safety initiatives from exemplar institutions and national and international quality improvement projects. This commentary provides a forum to disseminate this essential information internationally.