Human Error in Throat Pack Management: Report of Two Cases.
Throat packs are frequently used after tracheal intubation during ear, nose, and throat surgery. We report 2 cases of complications related to throat packs retained at the end of surgery. Miscommunication between anesthesiology and surgery teams on throat pack management led to an upper gastrointestinal endoscopy examination under general anesthesia in the first case and to severe respiratory distress requiring tracheal reintubation in the second case. Our 2 case reports highlight the importance of good communication between anesthesiology and surgery teams and of standardized procedures and checklists for the management of throat packs to ensure patient safety.
From the *Department of Anesthetics and Intensive Care, Rouen University Hospital, Rouen, France; and †Department of ENT Surgery, Rouen University Hospital, Rouen, France.
Violaine
V
Baranger
Nicolas
N
Bon Mardion
Bertrand
B
Dureuil
Vincent
V
Compère
D000328:Adult; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods*; D008297:Male; D019300:Medical Errors / Q000009:adverse effects*; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis* / Q000209:etiology*; D012128:Respiratory Distress Syndrome / Q000175:diagnosis / Q000209:etiology; D015503:Surgical Sponges / Q000009:adverse effects*