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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)


Latex: A Lingering and Lurking Safety Risk