Case study: COVID-19 swab snapped in tracheostomy

Through its review of recorded patient safety events the National Patient Safety Team identified the risk of part of a COVID-19 swab being left in the airway when testing patients with a tracheostomy.

A report described a routine SARS-CoV-2 swab being used to take a sample from a patient fitted with a tracheostomy. Part of the swab stylet snapped and was inadvertently dropped through the tracheostomy site. Initial CT imaging was reported as showing no signs of a foreign body but some inflammation. Bedside flexible endoscopy through the tracheostomy site revealed the swab in a right lobar bronchus. This was subsequently removed by flexible bronchoscopy.

It was found that the swab stick snap in half, as it was designed to do, to allow insertion into the specimen pot. A search of the National Reporting and Learning System (NRLS) identified other similar incidents. 

We shared our findings with Public Health England (now part of the UK Health Security Agency) who updated the guidance on their website to state that swabbing of the nose and throat was suitable for patients with a tracheostomy and/or a laryngectomy.

About our patient safety review and response work

The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare. The National Patient Safety Team identify new or under recognised patient safety risks, which are often not obvious at a local level. It does this through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources.

In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.

You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.

You can also find more case studies providing examples of this work on our case study page.