Poor tracheostomy care warning
Gaps in training may put patients with tracheostomies in life-threatening situations, the NHS in England, Wales and Northern Ireland is warned.
The tubes are fitted to allow patients to breathe and are being used more frequently in hospitals.
The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report called for improvement.
The Intensive Care Society said care was sometimes "below what is safe and reasonable".
A tracheostomy is used to help wean patients off ventilators and get them out of critical care beds and on to general wards.Blocked tubes
However, the report said training needed to improve on such wards - just 28% of hospitals trained staff to deal with a blocked or dislodged tracheostomy airway.
Dr Kathy Wilkinson, a consultant in anaesthesia and an NCEPOD clinical co-ordinator told the BBC: "There are more improvements that could be made and they're around training.
"One of most the common complications is a displaced or blocked tube, the patients lose their airway and it is a life-threatening emergency.
"The skills to sort this out need to be available or the patient can get into a lot of trouble quite quickly."
The report also questioned the choice of tubes used for some patients and raised concerns about patients being discharged overnight.Specialist expertise needed
About 12,000 of the procedures are carried out each year.
Mark Bellamy, president of the Intensive Care Society, said: "The ICS is concerned that levels of care available on general wards for patients with a tracheostomy in some cases fall below what is safe and reasonable.
"For this reason, intensive care units face delays in discharging patients with tracheostomies, who are otherwise well enough to be moved to general wards."
Dr Andrew Goddard, from the Royal College of Physicians, commented: "This report is very valuable in highlighting the areas of practice that need to be improved. In particular, it underlines the importance of not transferring patients between wards during the night, and the need for specialist expertise in managing patients with tracheostomies.
"Training in the management of patients with a tracheostomy also needs to be improved across all relevant health professionals, with readily available equipment, instructions and treatment protocols near the bedside."