Airway hazards

SALG is aware of a continued risk of aspiration of the plastic backing supplied with items commonly found in theatre areas such as ECG electrodes and silicone tape products. In 2020, a National Patient Safety Alert was issued that required NHS hospitals to introduce controls on purchasing to ensure that ECG/ECT electrodes for use in theatres, ECT suites and emergency areas have either large sheet backing for multiple electrodes or fully coloured or patterned individual backing.

It appears from recent reports that items are still being procured that do not comply with the requirements of the alert, particularly during periods of shortage. Some consumable items that were not specifically included in the alert, but which also are supplied with plastic backing, have been implicated in similar incidents. Additionally, some items that do comply with the alert remain a risk, due to the colour/pattern used being faint and/or similar to those commonly found in hospital linen and similar items.   

SALG would like to take this opportunity to ask individual anaesthetists to remain vigilant and report any ECG electrodes that do not meet the requirements of the alert to NHS England via SALG. NHS England and MHRA can take action if suppliers do not meet these requirements. SALG would like to highlight the importance of ensuring that all incidents and near misses involving plastic packaging becoming attached to airway equipment are reported through local incident reporting systems. Examples of compliant and non-compliant products are below.

Compliant product (photo reproduced with permission from Dr Katy Nicholson)

Non-compliant product (photo reproduced with permission from Dr Katy Nicholson)