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Abstract
Background
Adequate facemask ventilation during induction of anaesthesia is a key aspect of patient safety. Difficulties can therefore be life-threatening for the patient.
Case presentation
The case presented here illustrates a rare cause of an orbital fistula that led to a serious problem during facemask ventilation and demonstrates why team communication is so important.
Conclusions
Preparatory errors in patient assessment and anaesthetic preparation were identified as sources of error.
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