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We would like to report a near miss that we believe is likely to recur. During an elective operating list, as we inserted the laryngoscope blade (Truphatek International Ltd, Netanya, Israel) into the mouth of an anaesthetised patient, our vigilant anaesthetic nurse, who was positioned close to the head of the patient, suddenly lunged dramatically for the scope. She had noticed a nearly invisible scrap of clear plastic on the tip of the laryngoscope blade (Fig. 6). Although we routinely check the laryngoscope blade to ensure that the light is working, we had not seen the piece of plastic as it was attached to the inner aspect of the blade. Our experience is not unique. A search of the published literature has revealed a number of similar incidents [1, 2] and there has been a recent harrowing report of a clinical near miss involving a small disc of plastic wrapper causing complete obstruction of the anaesthetic circuit [3].

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Figure 6.  Small fragment of clear plastic wrapping on laryngoscope blade.

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Given that every component of the anaesthetic breathing system is wrapped in clear plastic packaging (Fig. 7), it is not surprising that similar incidents continue to occur. The risk is reduced if the package is opened along the perforations, but frequently these are poorly designed and it is easier to tear the equipment out of the wrapper. We have reported the incident to the manufacturer, the regulatory agent for the device and the National Patient Safety Agency. One way of reducing the risk would be through the use of coloured, semi-translucent wrapping material and the manufacturer has agreed to investigate this.

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Figure 7.  Clear plastic packaging of anaesthetic equipment.

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No external funding and no competing interests declared.

References

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  2. References
  • 1
    Chacon AC, Kuczkowski KM, Sanchez RA. Unusual case of breathing circuit obstruction: plastic packaging revisited. Anesthesiology 2004; 100: 753.
  • 2
    Foreman MJ, Moyes DG. Anaesthetic breathing circuit obstruction due to blockage of tracheal tube connector by a foreign body – two cases. Anaesthesia and Intensive Care 1999; 27: 735.
  • 3
    Anon. Breathing system obstruction: a cautionary tale. Anaesthesia News 2010; 278: 8.