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Who Nose Where the Airway Is?
Lee CR. AHRQ WebM&M [serial online]. October 2009.
Following surgery for peripheral vascular disease, a patient otherwise ready for discharge complains of liquid shooting from his nose. The surgeons make the patient NPO and order a consultation from an otolaryngologist, who discovers the nasopharyngeal airway still lodged in the patient's nasal cavity.
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Resource Type
Commentary
Setting of Care
Operating Room
Target Audience
Health Care Providers
Clinical Area
Anesthesiology
Vascular Surgery
Safety Target
Indwelling Tubes and Catheters
Medical Complications
Retained Surgical Instruments and Sponges
Error Types
Active Errors
Approach to Improving Safety
Structured Hand-offs
Human Factors Engineering
Medical Device Design