National Patient Safety Alert: Foreign body aspiration during intubation, advanced airway management or ventilation (1 September 2020)

Summary

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.

The most common types of foreign bodies identified in incident reports were transparent backing plastic from electrocardiogram (ECG) electrodes and plastic caps of unclear origin.

The alert asks providers to reduce this risk 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.