Patient safety alerts

Risk of Inadvertently Cutting In-Line (or Closed) Suction Catheters:
An incident has occurred recently where an in-line (or closed) suction catheter was left in the endotracheal tube (ET tube) by mistake. When the ET tube was cut to reduce the dead space, 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 bronchus. The tip was identified on a chest x-ray and subsequently removed by bronchoscopy.

Eight additional incidents describing retained suction tips have been reported to NRLS, STEIS and MHRA since January 1st, 2012. These cases involved neonates and adult patients and appear to have resulted in moderate harm. However, there is potential for serious harm because of the risk of infection and, especially in unstable patients, the undertaking of an invasive procedure to retrieve the foreign object.