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Airway complications are a leading cause of morbidity and mortality in anaesthesia1. Effective management of a difficult airway requires the timely availability of suitable airway equipment. The Australian and New Zealand College of Anaesthetists has recently developed guidelines for the minimum set of equipment needed for the effective management of an unexpected difficult airway (TG4 [2010] www.anzca.edu.au/resources/professionaldocuments ). TG4 [2010] is based on expert consensus, underpinned by wide consultation and an extensive review of the available evidence, which is summarised in a Background Paper (TG4 BP [2010] www.anzca.edu.au/resources/professional-documents ). TG4 [2010] will be reviewed at the end of one year and thereafter every five years or more frequently if necessary. The current paper is reproduced directly from the Background Paper (TG4 BP [2010]).

A 51-year-old female patient with Guillain-Batré syndrome was given three times the intended dose of intravenous human immunoglobulin while admitted to a tertiary intensive care unit. The error went unnoticed for seven hours and appears to have been the result of several successive breakdowns in communication between key staff. The patient, fortunately, made a full recovery. This report analyses the communication failure and explores possible ways of avoiding similar occurrences in the future.

Suboptimal communication between health professionals has been identified as a significant causative factor in incidents compromising patient safety. The use of a structured method of communication has been suggested to improve the quality of information exchange, particularly with inexperienced practitioners. One structure that has been suggested to improve communication is the situational briefing tool SBAR. This tool was developed by the US Navy for standardizing important and urgent communication in nuclear submarines. Despite its widespread uptake in some areas of healthcare, its effectiveness has until recently been unproven. This paper describes the benefits and pitfalls of methods we have used to prove the effectiveness of these communication tools.