Unintended extubation (UE) is the most serious risk associated with endotracheal intubation. In the pediatric population, UE can lead to significant patient harm. The target rate of UE cited in the literature is <1 per 100 ventilator days (VD). The United States organization Solutions for Patient Safety (SPS) has introduced a bundle to reduce UE in their cohort and has a goal of 0.95 per 100 VD. On average, each UE increases length of stay by six days and costs an additional $36,000.