BACKGROUND Tracheostomy is a frequently performed procedure, and historically has had a high reported complication rate. This has led some authors to suggest that a tracheostomy should be done only in the operating room (OR). Concerns regarding the hazards of transporting critically ill patients to the OR may inhibit the use of tracheostomy. Bedside tracheostomy in the Intensive Care Unit (ICU) has been shown to be safe, but this concept has not been widely accepted. METHODS We retrospectively reviewed consecutive patients undergoing tracheostomy over a four-year period and compared the safety of elective beside tracheostomy with OR tracheostomy. RESULTS We studied 536 patients who underwent tracheostomy during the four years, in 470 of whom the procedures were elective. Of these, 66 percent were done at the bedside without an anesthesiologist present. For the 311 patients who underwent bedside tracheostomy, the complication rate was 8.7 percent compared to 9.4 percent of 159 patients undergoing OR tracheostomy (p values were not significant). No deaths were directly associated with tracheostomy procedures, although the overall hospital mortality rate for these patients was 59 percent. CONCLUSIONS A tracheostomy can safely be performed in an ICU without requiring transport of the patient to the operating suite, thereby eliminating the hazards of transport.