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Publication Type: Patient Safety Advisory
Single or Multiple Incident: Multiple
Date: 3/1/2018 12:00:00 AM
This alert discusses the on-going patient safety incidents of exposure to latex products by patients with a known latex allergy. Pennsylvania healthcare facilities reported 616 latex-related events that occurred from 2014 through 2016, including 72 near miss events. Analysis revealed that latex indwelling urinary catheters were the most common source of inadvertent exposure in patients with documented latex allergies (75.0%, n = 408 of 544). Latex products that come in contact with mucous membranes (e.g., urinary catheters) cause more severe reactions than those that contact the skin (e.g., gloves), which makes the predominance of reports involving indwelling urinary catheters even more concerning. The perioperative care area accounted for the highest number of both exposures and near misses (57.1%, n = 352 of 616). Event narratives highlight contributing factors such as deficits in communication, documentation, supply management, and staff awareness. Strategies to address these contributing factors may include screening, thoughtful handoffs, evaluation of product alternatives, assessment of staff awareness, and observation of practice patterns. The majority of exposure events (98.7%, n = 537 of 544) were reported as Incidents (i.e., an event that could have injured the patient but did not either cause an unanticipated injury or require the delivery of additional health care services). Seven events were reported as Serious Events, all with a harm score of E (i.e., an event that occurred that contributed to or resulted in temporary harm and required treatment or intervention). Thirty-six unique medical products were described in the 544 exposure events. Indwelling urinary catheters were the most common source of latex exposure described in event narratives (75%), followed by gloves, Penrose drains, and red rubber catheters. The top 3 strategies to prevent patient exposures were staff recognition that the patient had no latex allergy wristband, staff identification of the allergy during a preoperative interview, and staff recognition that a latex allergy was undocumented. The alert provides discussion of contributing factors and risk reduction strategies.

Additional Details

Device:
indwelling urinary catheters, gloves, Penrose drains, red rubber catheters, tourniquets, intermittent urinary catheters, feeding tubes, Arrow cholangiogram kit, bone marrow collection kit, condom catheter, Davol drain, Holter monitor, leg bag, lithoplasty balloon, malecot catheter, probe cover, resistance band, rubber band, ster-strips, suprapubic catheter, T-tube, viewing wand cover, foley catheter, irritant contact dermatitis, allergic contact dermatitis, immediate hypersensitivity, funneling, urinary catheterization, phlebotomy, production pressure, workflow, distractions, door signs, chart stickers, elastoplast, root cause analysis, mental slips, normalized deviance, bar code technology
Medication/Gas/Fluid:
influenza vaccine, antibiotics, neuromuscular blocking agents, iodine
Medication/IV List:
neuromuscular blocking agents (e.g., succinylcholine, rocuronium, vecuronium)

Environment / Equipment
  1. Use latex-safe alternative gloves to set up the operating room until the patient is brought into the room and the patient's allergy status has been confirmed
  2. Identify and replace as many products as possible with suitable latex-safe alternatives.
  3. Evaluate all new product proposals for latex content.
  4. Make latex-safe supply carts available to all patient care areas. Establish a process to ensure carts are stocked and checked regularly.
  5. Ensure powdered surgeon's gloves, powdered patient examination gloves, and absorbable powder for lubricating a surgeon's gloves are no longer stocked or in circulation at your facility.
Communication
  1. Inform latex allergic patients and families of your organization's efforts to reduce latex exposure risk and engage them as partners in monitoring the environment and reminding all members of the care team about their allergy.
  2. Use latex precaution signs as visual reminders and an additional interdisciplinary communication tool. Consider placement on patient doorways, the inside and outside of operating room doors, above the head of the patient's bed, and on the anesthesia station in the operating room.
  3. As patients travel throughout the organization, ensure that receiving departments are notified in advance of latex allergic patients to allow time for adequate preparation.
  4. Use patient handoff tools that include communication about patient allergies.
  5. Incorporate a question asking explicitly about latex allergies into preoperative communication, including operating room scheduling forms, nursing-driven preoperative telephone calls, preoperative assessments, preoperative interviews, and preoperative checklists.
Rules / Policies / Procedures
  1. Establish a latex consultation service to help evaluate and manage latex allergic patients.
  2. Create an EHR latex allergy alert for indwelling and intermittent urinary catheter orders and an order that specifies to use a latex-safe alternative catheter.
  3. Include allergies in the preoperative time-out and consider using a checklist such as the one from the World Health Organization.
  4. When caring for latex allergic patients, check all product labels for latex and ask questions if labeling is unclear.
  5. Implement a latex allergy annual competency.
  6. Observe indwelling and intermittent urinary catheterization procedures for compliance with checking for a latex allergy prior to beginning the procedure.
  7. Review incident reports involving latex from the past 12 months to identify trends and opportunities.
  8. Establish a process for reviewing the latex content of all product substitutions sent by vendors and alerting frontline staff of any new products containing latex.
  9. Use signage in product storage areas to draw attention to products that are stocked as both latex and latex-safe alternatives.
  10. Leverage the bar code technology used for perioperative supply charges to link product information with patient allergy alerts.
Training
  1. Assess healthcare workers' knowledge and practices surrounding latex allergy screening, product labeling, and safety precautions when caring for patients with latex allergies; tailor educational interventions accordingly.
Regulation / Legislation
  1. Evaluate compliance with visual safety alerts, such as wristbands, signs, and chart stickers or bands. Consider packaging these alerts in a single bag for easier access and application.

Latex: A Lingering and Lurking Safety Risk