Targeted distribution of the National Patient Safety Agency Safer Practice Notice on throat packs.
Abstract: Using an electronic questionnaire, we tested the effectiveness of professional networks for distributing a National Patient Safety Agency Safer Practice Notice, 'Reducing the risk of retained throat packs after surgery', issued in April 2009. Using professional networks for the targeted distribution of guidance to specific professional groups was found to be effective.

KEYWORDS Throat packs / Patient safety / Surgery / Alert / Communication / Evaluation / Compliance / Professional networks
Subject: Surgical supplies (Usage)
Medicine (Practice)
Medicine (Analysis)
Patients (Care and treatment)
Patients (Analysis)
Authors: Durand, Marcus
Coates, Tracy
Flood, Chris
Norris, Beverley
Curran, John
Pub Date: 07/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: July, 2012 Source Volume: 22 Source Issue: 7
Product: Product Code: 3842101 General Surgical Supplies NAICS Code: 339113 Surgical Appliance and Supplies Manufacturing
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 300545546
Full Text: Background

Throat packs have been used in surgical procedures for over 150 years (Snow 1864). Leaving one in situ after surgery can obstruct a patient's airway (Hutton 2002) which is potentially life threatening. A survey of oral surgical practice in the UK (Knepil & Blackburn 2008) showed that the anaesthetist usually placed the throat pack (82%), but less frequently removed it (34%). In 29% of responses it was reported that packs were included in swab counts. In 22% of responses, participants were aware of incidents involving unintended retention of throat packs in the previous five years.

'Responsibility for removal [of a throat pack] devolves to the person who inserted it [and] all who are present must see it removed.' (Crawford 1977).

Failures to remove throat packs continue to be reported despite recommended practice by Snow in 1858 and published methods to prompt for their removal (Najjar & Kimpson 1995, Burden & Bliss 1997, To et al 2001, Basha et al 2006).

Throat packs are sometimes deliberately left in place, such as when patients are transferred to a critical care facility. In many industries, formal protocols are used to prompt the execution of essential procedures, especially in special circumstances (Toff 2010). In the context of throat packs prompts to remove them must cater for cases when they must be left in place for a while. It is also important that prompts for removal must work regardless of changes to team members during an operation.

The National Reporting and Learning System (NRLS) of the National Patient Safety Agency (NPSA) contains 38 cases of unintentional retention of throat packs for the years 2006 and 2007. Twenty were graded by reporters as resulting in no harm, 17 in low harm' and one in 'moderate harm', although the potential for significant harm is known to be high, with a possible risk of death (Najjar & Kimpson 1995, Snow 1858).

Responses to the NPSA from professional bodies such as the Association for Perioperative Practice (AfPP), the Royal College of Anaesthetists (RCoA ), the Association of Anaesthetists of Great Britain and Ireland (AAGBI), the College of Operating Department Practitioners (CODP) and Royal College of Nursing (RCN) indicated that although there was recognition of good practice, this was not implemented in all hospitals. Repeated reports at long intervals from the same hospitals implied that little was being done by organisations to sustainably address the problem.

The Safer Practice Notice

'Improvement through partnership' was a collaborative venture between the NPSA and the RCoA designed to promote joint improvement projects. As part of the initial scoping of patient safety issues, the combination of suspected low reporting, serious consequences and lack of analysis regarding retained throat packs was identified as potentially dangerous. As a result, a working party was formed by members of the RCoA, the AAGBI, the AfPP, the CODP and relevant experts from the NPSA. The working party studied data from literature review, incident reports and information from the NHS Litigation Authority and professional medical defence organisations to devise advice on possible solutions to prevent unintentionally retained throat packs. This resulted in the NPSA's Safer Practice Notice (SPN) 'Reducing the risk of retained throat packs after surgery (NPSA 2009).

The throat pack SPN provides guidance to prevent unintentional retention of throat packs and encourages organisations to implement a policy and procedure which reflects this guidance. The supporting information accompanying the SPN consists of a thematic literature review, a risk assessment document and an algorithm that conforms to the recommendations of the SPN.


Guidance from the NPSA in the form of alerts, Rapid Response Reports and Safer Practice Notices are normally only distributed through the Department of Health's Central Alerting System (CAS, This time, as well as being issued via the Central Alerting System, the SPN was made available on the websites of the AAGBI, RCoA, AfPP, CODP and RCN. Network members were alerted to this by their network managers through the methods normally used to communicate with them such as email, cell phone text messages or the mail service.

Three months after the release of the SPN, the use of the Central Alerting System as well as professional networks were evaluated for their effectiveness in delivering it to anaesthetists and related professionals. The aim was to understand how these professionals received this type of guidance so that this knowledge might be applied to future targeted NPSA products. Another objective was to examine the efficacy of using professional networks to communicate guidance by analysing the results from a questionnaire and examining compliance data.


Eighteen weeks after the release of the SPN, an electronic link to an online questionnaire using SelectSurvey ( was emailed to as many clinical staff members as possible via patient safety and governance leads in NHS hospital trusts. The questionnaire asked about the communication of the SPN and what they thought of it.

To get the views of those for whom the throat packs SPN was most relevant and further test the use of professional networks, the link to the online questionnaire was also distributed to their members by specially tasked 'linkmen' of the AAGBI ( through their email network. Delegates attending the Association for Perioperative Practice (AfPP) conference in October 2009 were also asked to complete the online questionnaire.

The questionnaire consisted of both open and closed questions. Since not all the questions were applicable to everyone, the results for the closed questions were expressed as percentages of responses to the particular questions. Although this may appear to potentially bias the results because each question has a different denominator, it is more relevant than using the total respondents as the denominator because not everyone answered all the questions. Qualitative methods were used for analysis of the open questions to identify themes and discussion points from the free text.

The Department of Health requires that organisations report their state of compliance with alerts. The Central Alerting System provides a facility for this by allowing trusts to select their current status with each alert from a list of pre-defined levels such as 'Action Not Required', 'On-going' or 'Complete'. These reported compliance levels were captured 30 weeks after release of the SPN and an analysis was made of the percentage of organisations at each level of compliance.


It was recognised that the online questionnaire might have had an effect on the implementation of the SPN by drawing attention to it and thereby prompting action. This was assessed by analysing compliance data collected periodically from the 28 April to the 28 November 2009. This period covered the distribution of the questionnaire and the AfPP conference in October 2009. These data were examined for points where the rate at which organisations reported their implementation as 'Completed' may have changed.


Implementation of the Safer Practice Notice

Four weeks after release of the throat packs SPN, 388 of 389 NHS trusts had acknowledged receipt and after seven weeks, all had done so. The analysis of implementation of the actions within the SPN seven months after release is summarised in Table 1. At this point, 341 (88%) of all 389 trusts had either completed implementation or stated that the SPN was not relevant to them, 21 (5%) were in the process of implementation and 27 (7%) had not yet started.

If it is assumed that the SPN was not relevant to those trusts that reported 'Action Not Required', then of the 200 'relevant trusts', 152 (76%) had completed implementation after 30 weeks, while 21 (10.5%) were still undertaking work and 27 (13.5%) had not started.

Figure 1 shows that almost half of all trusts had complied with the SPN by the fourth week. A marked increase during September and October coincided with the launch of the online questionnaire and the AfPP conference.

Survey results

Table 2 shows that anaesthetists provided most of the responses to the questionnaire; the rest came from nurses, operating department practitioners and managers. Table 3 shows when respondents remembered first seeing the SPN.

Table 4 shows how the SPN was received. The most common method was via email, followed by newsletters and websites. These categories are not exclusive; many responses indicated more than one method. Website access was mainly through the NPSA and the RCoA ( ( Further respondents stated that they had been made aware of the SPN through briefings or seeing it on notice boards, while others reported first learning of it through participation in this survey, exemplified by a respondent's comment:

'via email requesting taking this survey-brief discussion of guidelines at departmental meeting and decision that we already employ the guidance'.

Table 5 shows where the emails originated; most were from within the respondent's own organisation. They came mainly from clinical directors and governance leads but also from a wide range of other professional groups. Consultant clinicians, some of whom would have been linkmen of the AAGBI, were the originators of about 20% of these internal emails. Others were directly from professional networks and the NPSA. Most of those who had received the email from any other source indicated that it had come via the Central Alerting System.

About half of those that received the SPN passed on information to a wide range of colleagues.


The NPSA's SPN on throat packs, which was issued via the Central Alerting System and distributed through professional bodies, linkmen and websites, was received by many of the targeted readers. Fifty two percent of respondents to a questionnaire recalled seeing it. The majority had seen it within one month of issue.

The number of anaesthetists that responded to the questionnaire suggests that specialists can be effectively targeted through specific professional networks. Not only anaesthetists, but a range of professions responded to the questionnaire, indicating useful cross-professional communication and interest.

Responses in the questionnaire showed that the SPN and supporting information had a high degree of acceptance and adoption. This is supported by the rapid early compliance rate seen in the Central Alerting System data shown in Figure 1. This early compliance may suggest an underlying degree of good practice already in place. The steady rise in compliance after that suggests that it was not too difficult for trusts to comply with the guidance. A marked increase in compliance which corresponded with the launch of the questionnaire for this study and the AfPP conference, suggests that these may have raised awareness of the SPN and the approaching deadline for compliance, prompting a response. This is supported by statements indicating that the survey had prompted awareness of the SPN.

Emails sent from reputable sources were effective in getting the message to the right people. Supported by access to resources on the web sites of trusted organisations, these proved helpful in further distribution.


The NPSA is to be abolished in 2012 and although some of its functions will be transferred to the new NHS Commissioning Board and elsewhere, it is still not clear whether this type of alert will be produced by any new organisation. Our findings are still useful, especially to learned societies, associations and colleges who will continue to distribute targeted guidance and alerts to their members.


Basha S, McCoy E, Utlah R, Kinsella J 2006 The efficacy of pharyngeal packing during routine nasal surgery-a prospective randomised controlled study Anaesthesia 61 (12) 1161-5

Burden R, Bliss A 1997 Residual throat pack--a further method of prevention Anaesthesia 52 (8) 806

Crawford B 1977 Prevention of retained throat pack British Medical. Journal. 2 (6093) 1029

Hutton P 2002 Fundamental. principles and practice of anaesthesia London, Martin Dunitz

Knepit G, Blackburn C 2008 Retained throat packs: results of a national survey and the application of an organisational accident model British Journal of Oral & Maxillofacial Surgery 46 (6) 473-6

Najjar M, Kimpson J 1995 A method for preventing throat pack retention Anesthesia & Analgesia 80 (1) 208-9 National Patient Safety Agency 2009 Reducing the risk of retained throat packs after surgery-Safer Pratice Notice NPSA/2009/SPN001 Available from: [Accessed March 20121

Snow J 1858 On chloroform and other anaesthetics: their action and administration Reprinted in British Journal of Anaesthesia 1954 26 (5) 337-42

To E, Tsang W, Yiu F, Chan M 2001 A missing throat pack Anaesthesia 56 (4) 383-4

Toff N 2010 We need a safety system (and an operations manual) British Medical Journal 340 c917

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by Marcus Durand, Tracy Coates, Chris Flood, Beverley Norris, and John Curran Correspondence address: Quality, Reliability, Safety and Teamwork Unit, Nuffield Department of Surgical Science, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU. Email:

About the authors

Marcus Durand BSc (Hans), PhD

Former Research and Evaluation Lead at the NPSA. Currently with the Quality, Reliability, Safety and Teamwork Unit, Nuffield Department of Surgical Science, University of Oxford, John Radcliffe Hospital, Oxford

Tracy Coates RGN

Former Patient Safety Lead-Anaesthesia, National Patient Safety Agency, President AfPP

Chris Flood RGN, RN (MH), BSc, MSc

Senior Lecturer, City University, London

Beverley Norris BSc (Hans), PhD

Human Factors Lead, National Patient Safety Agency

John Curran MB, BS, PhD, FRCA

Consultant Anaesthetist (retired)

No competing interests declared
Profession         Number (Percentage)

Anaesthetists                  458 (82)
Nurses and ODPs                     10)
Managers                         28 (5)

Total                              558

Table 2 Questionnaire respondents

SPN seen             Number (Percentage)

Within one week                142 (49)
Within one month                61 (21)
Couldn't remember               87 (30)

Total                              290

Table 3 first sight of the Safer Practice Notice

Non exclusive
categories    Number (Percentage)

Emails                                   198 (70)
Bulletin or newsletter                    50 (18)
We bsites                                 35 (12)
Briefings or Meetings                      24 (9)
Notice Boards                              17 (6)

Table 4 Communication methods

Where did email originate?     Number (Percentage)

From within my organisation                122 (62)
Professional network                        34 (18)
N PSA                                       33 (17)
1 Central Alerting System                     6 (3)
Can't remember                                3 (2)
LTota                                           198

Table 5 Email sources
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