A patient presented to the emergency department with complaints of abdominal pain. A thorough workup identified that the patient was suffering with a hiatal hernia; the patient was admitted to the hospital with a plan for operative repair. The surgical team proceeded to the operating room (OR) after allowing an appropriate time for anticoagulant washout. In the preoperative area, the patient notified the surgeon that he has an adhesive allergy and a list of safe products was available in his medical record. The surgeon notified the anesthesia team of the allergy discussion that took place with the patient, and they decided to use paper tape to secure the patient’s endotracheal tube and eyelids (to prevent corneal anesthesia while under general anesthesia). After a successful hernia repair, the certified registered nurse anesthetist removed the tape from the patient’s eyelids. During this removal, the patient sustained significant skin tears to their lower eyelids. These injuries required a plastic surgery consult and ongoing treatment after discharge.
A team of hospital executives, anesthesia providers, the surgical team, surgical services leadership, patient relations, and patient safety formed to review this patient’s case. Their detailed analysis identified many system opportunities, among which concerns with product availability, hand-offs, and communication with the patient were highlighted as top priorities. The local anesthesia group created a severe skin allergy kit that included hypoallergenic products that may be safe to use on patients presenting to the facility with adhesive allergies. They made this kit available in the OR, specifically, but the house supervisors were also given a kit for patients presenting through other entry points outside of the OR.
Additionally, this team recognized a larger global impact: If they did not have the appropriate hypoallergenic adhesive products available, it was likely that sister facilities also did not have these items. The team disseminated this case study across the entire hospital system, spurring systemwide discussions for organizational change. Through these broad discussions, it was identified that adhesive allergies do not stop with tapes but also extend to intravenous dressings, wound care products, electrocardiogram patches, and more. Supply chain was pulled in to review available products and help identify safer products for patients presenting with adhesive allergies. Case studies were also presented to nursing councils in multiple hospitals to increase situational awareness related to verifying allergies and including the patient in the product selection.
This was an unfortunate event for this patient; however, by increasing transparency related to it, this team ultimately drove organizational change, which led to a safer environment for patients across the system.