The Lost Nasopharyngeal Airway: A Sentinel Event to Ponder?

Aspiration of the nasopharyngeal airway (NPA) is one of the rarest and life-threatening complications. In the literature, very few cases have been reported. The advent of NPA to protect the airway in semiconscious patients acts like a double-edged sword, based on the patient's condition. The patient factor plays a crucial role. Here, we are reporting a case of aspirated NPA due to the patient's poor gag reflex and human factors at the workplace. The incidence can be minimized if proper handover and documentation by caring personnel are done, which will help reduce the risk of aspiration.