During the first 12 months of mandatory reporting, skin tears were reported 2,807 times through the Pennsylvania Patient Safety Reporting System.
Skin tears can be sizeable and, in some cases, require more than the selection of the correct dressing as the following cases indicate:
While transferring the patient from the bed to the chair with a total assist, the left leg was lifted and a 10 cm x 10 cm skin tear resulted. The physician ordered Vaseline gauze and a dressing. Further discussion with the attending resulted in suturing and stapling the area.
Patient was found on floor after staff member heard bed alarm and thud. Skin tear assessed and treated, requiring suturing to left forearm.
Use of equipment, patient transfers or falls, treatments and procedures all place the patient at risk of incurring a skin tear, as these cases illustrate:
When taking off the EKG lead the skin ripped off the patient (8 cm x 3 cm).
When removed from the bedpan a 2 cm x 1 cm skin tear occurred. Wound was dressed with a dry sterile dressing and tape.
Reported events demonstrate that the risk of skin tears increases with age, as shown in Figure 1.
Figure 1. Reports of Skin Tears per 100,000 Patient Days by Gender and Age Cohort (Jul 2004-Jun 2005)
Skin tears are most frequently reported from general Med/Surg units, which account for 33.2% of reported cases
Figure 2. Reports of Skin Tears by Department or Unit
Excerpted from: Skin tears: the clinical challenge. PA PSRS Patient Saf Advis 2006 Sep. http://patientsafety.pa.gov/ADVISORIES/Pages/200609_01b.aspx.