Retained throat packs: results of a national survey and the application of an organisational accident model.

Throat packs are commonly placed in the patient's pharynx before oral surgical procedures under general anaesthesia. The pack is thought to protect the airways from aspiration of surgical debris, but if it is retained after extubation it can obstruct the airway. Adverse incidents after retention of throat packs have been reported anecdotally, but to our knowledge the risk management practices undertaken and common events surrounding retention of throat packs, have not been published before. We investigated the management of throat packs in 2007, by sending a questionnaire to maxillofacial surgeons and anaesthetists in the UK. We discuss the results and apply them to an organisational accident model.