A stage one warning has been issued on the risk of inadvertently cutting in-line (closed) suction catheters. The alert has been issued to all NHS hospitals and community services in England that use in-line or closed suction systems as part of patient care.

• Risk of inadvertently cutting in-line (closed) suction catheters

This follows a recent incident where an in-line (or closed) suction catheter was left in the endotracheal tube (ET tube) by mistake. When the ET tube was cut, the suction catheter was also cut and the tip remained in the ET tube. The incident was not noticed for several days and during this time the tip of the suction catheter migrated into the patient’s main airway. The tip was identified on a chest X-ray and subsequently removed by bronchoscopy.

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