DISPOSABLE LIGHTED BOUGIE TIP 40

Description of Event or Problem

THE TIP OF A LIGHTED BOUGIE WAS RETAINED IN A PT'S ESOPHAGUS FOLLOWING REMOVAL OF A LIGHTED BOUGIE. THE LIGHTED BOUGIE WAS USED DURING A LAPAROSCOPIC NISSEN PROCEDURE AND THE SEPARATION OF THE TIP WAS NOT RECOGNIZED. ON THE MORNING FOLLOWING SURGERY, PT COMPLAINED OF NAUSEA, VOMITING AND A PAIN SCORE OF 12/10. FOREIGN OBJECT IDENTIFIED IN THE POSTERIOR ORAL PHARYNX AND REMOVED AT BEDSIDE WITH FORCEPS. FOREIGN OBJECT IDENTIFIED AS THE DISPOSABLE TIP OF A LIGHTED BOUGIE. PERMANENT HARM WAS NOT ASSESSED. FDA SAFETY REPORT ID# (B)(4).