AnaesthesiaVolume 58, Issue 2 p. 186-187 Free Access A ‘foreign body’ in the circuit filter First published: 23 September 2008 https://doi.org/10.1046/j.1365-2044.2003.03005_7.xCitations: 1AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Circuit obstruction has made national news recently. We wish to report another critical incident involving a foreign body in a circuit filter. One of the authors (GR), on opening the packet containing the heat and moisture exchanger (Air Safety Limited, Morecambe), noticed an ‘extraneous luer lock cap’ trapped on the patient side of the filter (Fig. 1). This was in addition to the cap that is normally screwed on to the carbon dioxide port. The offending object was ‘loosely’ trapped in the filter and as a result could potentially have entered the catheter mount and possibly the patient's airway. The filter was photographed and the manufacturers have been informed. Figure 1Open in figure viewerPowerPoint Reports of foreign objects in the circuit make disturbing reading. In this case it would appear that this was as a result of failure of quality control. Fortunately, in our situation the vigilance of a consultant anaesthetist prevented what might have been a potentially serious incident. Once again we urge all anaesthetic personnel to maintain utmost vigilance and to carry out routine checks despite the pressures of modern day practice. K. RamachandranS. ChadwickG. Robson North Manchester General Hospital, Manchester M8 5RB, UK References 1 Checklist for Anaesthetic Machine (2). Association of Anaesthetists of Great Britain and Ireland. 2000, London. Google Scholar 2 Medical Devices Agency. Anaesthetic Breathing System Components; Pre-use checks. HN 2001 (07) March, 2001. Google Scholar A reply Air Safety Limited has made over 12 million filters and this is the first time that we have received a report of a gas analyser port cap being loosely trapped in a filter. We understand that this type of incident has happened to other manufacturers and have therefore taken great care to operate procedures that should prevent such an occurrence. However, this occurrence was reported to us in August 2002 and has been fully investigated. Whilst this was clearly an isolated incident, Air Safety Limited has now chosen a new red gas analyser port cap so that in the unlikely event of a recurrence, the cap would be very visible. The red cap is in complete contrast to the White, Blue and Green medias that we use in this filter range and would therefore be much easier for our operatives to detect (Fig. 2). Figure 2Open in figure viewerPowerPoint Picture of how the red cap would be easier to detect if the 12 000 000 to 1 problem should re-occur. Our investigations into other potential solutions are ongoing as part of our continuous improvement programme. M. Nicholson Frenchurch Environmental Group (Air Safety Ltd) E-mail: marjorienicholson@fengroup.com Citing Literature Volume58, Issue2February 2003Pages 186-187 FiguresReferencesRelatedInformation