10/17/2014 Throat Packs

http://www.nrls.npsa.nhs.uk/resources/?entryid45=59853 1/2
Reference number
0815
Central Alert System (CAS) reference
NPSA/2009/SPN001
Issue date 28 April 2009
Action date (if applicable) (date field) 14 October 2009
DH Gateway reference
11700
Type Alert
This Safer Practice Notice applies to all members of theatre teams and aims to reduce the risk of throat packs being retained
after surgery is completed.
Throat packs are often inserted by anaesthetists or surgeons to:
absorb material created by surgery in the mouth;
prevent fluids or material from entering the oesophagus or lungs;
prevent escape of gases from around tracheal tubes; and
stabilise artificial airways.
However, if a throat pack is retained after surgery is completed, it can lead to obstruction of the patient's airways.
Data received by the Reporting and Learning System between 1 January 2006 and 31 December 2007 were analysed. Thirty-
eight incidents were identified, of which 24 were unintended retention of throat packs; one resulting in moderate harm. Further
incidents were identified from a literature search and through professional networks.
Clinical risk managers responsible for anaesthesia and surgery should ensure that local policies and procedures are adapted
to state that:
The decision to use a throat pack should be justified by the anaesthetist or surgeon for each patient. This person
should assume responsibility for ensuring the chosen safety procedures are undertaken.
At least one visually-based and one documentary-based procedure is applied whenever a throat pack is deemed
necessary.
All staff are fully informed of the chosen procedures.
Although the deadline for actions has passed, this guidance remains best practice. It should be followed to prevent future
patient safety incidents.
Reducing the risk of retained throat packs after surgery - Safer Pratice Notice - 342 KB
0815 - Reducing the risk of retained throat packs after surgery - Safer Pratice Notice - 2009-04-28 - V1
Reducing the risk of retained throat packs after surgery flowchart - 130 KB
0815A - Reducing the risk of retained throat packs after surgery flowchart - 2009-04-28 - V1
Reducing the risk of retained throat packs after surgery supporting information - 276 KB
0815B - Reducing the risk of retained throat packs after surgery supporting information - 2009-04-28 - V1
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10/17/2014 Throat Packs
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