Case study: Risk of airway obstruction from green anaesthetic swabs

Through its core work to review recorded patient safety events, the National Patient Safety Team identified a risk of harm from green anaesthetic swabs obstructing the patient airway. 

A post operative patient had an i-gel® airway device (used to secure a patient’s airway) removed in the recovery room. Upon removal, the patient began to struggle to breathe. On investigation a green anaesthetic swab was found in the upper airway and removed. The swab had reportedly been inserted to help obtain a seal in the patient’s oropharynx by supporting the i-gel® position.

A review of the National Reporting and Learning System (NRLS) identified eleven incidents over a three-year period relating to green swabs in or around the mouth, causing (or with the potential to cause) an airway obstruction.

We liaised with the Safe Anaesthesia Liaison Group (SALG), the Royal College of Surgeons, the Faculty of Dental Surgery and the Centre for Perioperative Care (CPOC). CPOC agreed to strengthen guidance in this area. The recently revised National Safety Standards for Invasive Procedures (NatSSIPs 2), which are used across the NHS to reduce misunderstandings or errors and to improve team cohesion, now includes a standard for the ‘Reconciliation of Items in the Prevention of Retained Foreign Objects’ which states ‘The mouth represents a danger zone. Green gauze should never be used to stabilise an airway.’

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.