Since June 2004, the Pennsylvania Patient Safety Reporting System (PA-PSRS) has received two reports indicating problems with tubular dressing retainers. The reports indicated that the patient’s circulation was compromised due to use of incorrect size and improper application of the dressing. The reports below illustrate harm to patients.
[Patient] came to the emergency department (ED) for laceration of finger. [The laceration was] treated and [patient was] released. [The patient] returned for dressing being wrapped too tight. The wound assessment identified the wound to be healing satisfactorily. The finger was dressed with the wrong dressing size; tubular dressing retainer size 1 had been used as the dressing. [emphasis added] It was meant to be used as a single strip to hold the actual dressing in place. The area [appeared necrotic], requiring amputation of the finger tip.
The patient [was seen in] the ED for cuts on two fingers. [Patient] presented again [a few] days later with impaired vascular status of digits. The wrong dressing was used: tubular dressing retainer size 1. This was meant to be a single strip to hold the actual dressing in place; instead, it was used as the dressing. It got tighter with each successive application and turn of the metal ring. The patient was referred to a plastic hand [specialist] for surgery. The patient is currently undergoing physical therapy.
A search of the U.S. Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database using the keyword search term “tubular dressing retainer” revealed five reports between 1992 and 1998 describing events of vascular complications following application of tubular dressing retainers on digits including the thumb. Similar to the PA-PSRS reports, the MAUDE reports describe patients complaining of increased pain during a two-to-three-day period after application of the dressing retainer. Removal of the dressing and reassessment of the wound did not occur until several days after the dressing was applied, despite early onset of pain. Vascular compromise was identified during reassessment, and symptoms ranged from discoloration of the digit to permanent disability and, in some cases, amputation of the digit.
Facilities may reduce harm to patients by implementing processes to improve the safe use and application of tubular dressing retainers. For example, education for physicians, nurses, and other healthcare providers involved in the application of these dressings can include correct application and awareness of the mechanisms that may result in complications (see Figure).
Excerpted from: Tubular dressing retainer: retention without restriction. Pa Patient Saf Advis 2008 Dec. http://patientsafety.pa.gov/ADVISORIES/Pages/200812_127.aspx.