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Safety warning on foreign body aspiration during intubation

A National Patient Safety Alert has been issued on the risk of foreign body aspiration during intubation, advanced airway management or ventilation.

Foreign body aspiration can occur if loose items are unintentionally introduced into the airway during intubation, ventilation or advanced airway management. This can lead to partial or complete airway blockage or obstruction, and if the cause is not suspected, can be fatal.

Over a six-year period, the NHS England and NHS Improvement patient safety team identified five incidents where a foreign body (FB) was aspirated, and a further four incidents where the FB was identified during intubation and removed. The most common types of FB identified in incident reports were transparent backing plastic from electrocardiogram (ECG) electrodes and plastic caps of unclear origin. This is likely to be an under-estimate of the true number of incidents as many may go unrecognised. 

During an investigation it was also identified that: 

• Some breathing circuit components with untethered caps are still available to purchase. 

• Airway trays for routine or planned procedures are frequently prepared in advance, but left uncovered, and as a result loose FBs may become attached to breathing system devices. 

• The ends of breathing system hoses are not routinely closed between patient cases, allowing the potential for loose plastic objects to enter the breathing hose system. 

The alert asks providers to reduce the risks by purchasing safer alternative equipment without loose and transparent parts. Providers are also asked to develop or amend local protocols to ensure pre-prepared intubation and advanced airway management devices are covered or protected until use; and that the ends of reusable breathing system hoses are closed between patient cases.

Failure to take the actions required under the National Patient Safety Alert may lead to CQC taking regulatory action. The alert can be accessed here.

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Upcoming Events

Central Sterilising Club - Annual Scientific Meeting 2024

Crowne Plaza at Gerrard’s Cross
15th April 2024 – 16th April 2024

DECON UK 2024

National Conference Centre, Birmingham
17th April 2024

Infection Prevention & Control

National Conference Centre, Birmingham
23rd - 24th April 2024

Theatres & Decontamination Conference 2024

Coventry Building Society Arena
16th May 2024

The AfPP Roadshow - Birmingham

Millennium Point, Birmingham
18th May 2024

The AfPP Roadshow - Exeter

University of Exeter
22nd June 2024

Access the latest issue of Clinical Services Journal on your mobile device together with an archive of back issues.

Download the FREE Clinical Services Journal app from your device's App store

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