Nonsurgical burn injuries, invasive group A streptococcus, wrong-site surgery and more in the March 2018 Pennsylvania Patient Safety Advisory
Harrisburg, Pa., March 22, 2018 — Maintaining a latex-safe healthcare environment can be a challenge for healthcare facilities. Despite the decreasing incidence of latex allergies, the potential for significant patient harm remains.
"The correlation between latex allergies and gloves has become so intertwined, that other threats in healthcare environments that exist for those who have a latex allergy can be overlooked," said Dr. Ellen S. Deutsch, medical director for the Pennsylvania Patient Safety Authority. "Reactions from latex allergies can be life threatening safety events; identifying products that contain latex and assessing the risk for patient harm is essential."
Analysis of latex-related events reported to the Authority between 2014 and 2016 identified 616 events. Those 616 events consisted of 72 "near misses" (events that might have caused harm but did not reach the patient), 537 exposure events (breaches in latex precautions that reached the patient), and 7 Serious Events, (events resulting in patient harm).
Latex indwelling catheters were the most common source of unintended latex exposure (75%, n= 408 of 544). An additional thirty-five unique latex containing products were mentioned in event narratives, most notably gloves, Penrose drains, and red rubber catheters. The majority of both exposure and near miss events occurred in perioperative care areas (57.1%, n= 352 of 616).
Event narratives revealed (1) a variety of contributing factors for latex exposure events and (2) success modes for prevention. Lack of communication, poor documentation, and ineffective product management all contributed to unintended latex exposure events. Conversely, success modes for prevention included thorough patient assessments, acute observation of missing allergy wristbands, and handoff communication.
"It can be exciting when risk reduction strategies regarding a complex patient safety challenge, such as latex allergies, have been successful," says Deutsch. We must be careful not to forget that risk reduction is not eradication; there is still a small, but significant population that remains at risk for patient harm."
In the Authority's March 2018 Pennsylvania Patient Safety Advisory article, "Latex: A Lingering and Lurking Safety Risk," the Authority discusses latex allergy exposures and strategies for prevention. A standalone graphic further highlights the important factors in protecting patients with latex allergies.
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The Authority's mission is to improve the quality of healthcare in Pennsylvania by collecting and analyzing patient safety information, developing solutions to patient safety issues, and sharing this information through education and collaboration. Its vision is safe healthcare for all patients.