Description of Event or Problem · 1
MALE BURN PATIENT WAS VERY RESTLESS AND AGITATED AFTER DEBRIDEMENT SURGERY. THE PATIENT WAS TRYING TO PULL OUT THE ENDOTRACHEAL TUBE. THE PATIENT WAS BITING THE TUBE AGGRESSIVELY SO THE RT AND THE RN ATTEMPTED TO PLACE A UNIVERSAL BITE BLOCK. THE BITE BLOCK HAS A ZIP TIE END WHICH IS ATTACHED TO THE BLOCK. THE END OF THE ZIP TIE HAS A PLASTIC BLUE CAP (POSSIBLY TO KEEP IT FROM POKING THROUGH THE PACKAGING). THE PLASTIC BLUE CAP FELL OFF THE TIP AND LANDED IN THE PATIENT'S MOUTH. THE RT AND THE RN ATTEMPTED TO RETRIEVE IT BUT IT DISAPPEARED. IT IS PRESUMED THE PATIENT SWALLOWED IT. THE STAFF WILL MONITOR THE PATIENT'S BOWEL MOVEMENTS IN THE MEANTIME. A XRAY WAS OBTAINED. UNFORTUNATELY, THE CAP IS NOT RADIOPAQUE, SO IT COULD NOT BE FOUND ON X-RAY. ALTHOUGH THE PATIENT IS NOW EXTUBATED AND BREATHING WELL, ASPIRATION CANNOT BE COMPLETELY RULED OUT. HOWEVER, IT IS NOT BELIEVED THAT THE PATIENT ASPIRATED THIS CAP. THE PATIENT STILL HAD THE ET TUBE CUFF INFLATED SO IT WOULD HAVE BEEN DIFFICULT FOR THE CAP TO PASS THE CUFF. THE SURROUNDING AREAS WERE SEARCHED AND THE CAP WAS NOT LOCATED. THE PACKAGING DOES NOT HAVE ANY INDICATION LISTED ABOUT REMOVING CAP BEFORE USE.