Patient Safety Advisory Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 3, No. 1 (March 2006) Produced by ECRI & ISMP under contract to the Pennsylvania Patient Safety Authority Mix-up Between Skin Prep Solution and Adhesive Remover P A-PSRS received two reports from one hospital describing a mix-up between skin prep solution and adhesive remover. A hospital staff member mis- items and also forms a film on skin to help reduce friction when those items are removed from the pa- tient. The Smith & Nephew adhesive remover is used takenly used an adhesive remover on two patients to soften the adhesives on items such as tapes and to instead of a skin prep solution prior to applying Holter remove adhesive residue. monitor electrodes. Both events resulted in the pa- tients experiencing erythematous skin reactions at the electrode sites. Added Color Scheme Larger Font Size Added Color Scheme Larger Font Size Figure 2. New Style of Packaging for Skin Prep (top) and Adhesive Remover (bottom) Figure 1. Current Style of Packaging for Skin Prep (top) and Adhesive Remover (bottom) In response to prior reports of the packages looking similar and in response to the events above, Smith & The events occurred because the packaging for both This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 3, No. the skin prep and adhesive remover are very similar 1—March 2006. The Advisory is a publication of the Pennsylvania Patient in appearance (see Figure 1). The skin prep and ad- Safety Authority, produced by ECRI & ISMP under contract to the Authority as hesive remover are manufactured by Smith & part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). Nephew, Inc. (Cat. Nos. 420400 and 403100, respec- Copyright 2006 by the Patient Safety Authority. This publication may be re- tively) and have the same orange and white pattern printed and distributed without restriction, provided it is printed or distributed in with black lettering. its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. The Smith & Nephew skin prep is a liquid prep solu- To see other articles or issues of the Advisory, visit our web site at tion used to prepare skin for tapes or similar adhesive www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. ©2006 Pennsylvania Patient Safety Authority Page 1 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 3, No. 1 (March 2006) Mix-up Between Skin Prep Solution and Adhesive Remover (Continued) Nephew took steps to redesign the packaging for the Healthcare facilities that use the above products can skin prep and adhesive remover (see Figure 2). The alert users to the information in this article, emphasiz- front of the redesigned skin prep package now con- ing the need to carefully scrutinize the packaging tains a green block of color containing the Cat. No. when obtaining either the skin prep solution or the 420400, and the front of the redesigned adhesive re- adhesive remover. Until the newly designed packag- mover package contains a maroon color containing ing is available, consider providing signage or other the Cat. No. 403100. Both packages use a larger identifiers near the products to alert users to the simi- black font to distinguish one from the other. According lar packaging of these products. to Smith & Nephew, the new style packaging has been implemented. However, it may not be available in the market until the second quarter of 2006 due to inventory depletions in the market. Page 2 ©2006 Pennsylvania Patient Safety Authority Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 3, No. 1 (March 2006) An Independent Agency of the Commonwealth of Pennsylvania The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI, as contractor for the PA-PSRS program, is issuing this newsletter to advise medical facilities of immediate changes that can be instituted to reduce serious events and incidents. For more information about the PA- PSRS program or the Patient Safety Authority, see the Authority’s website at www.psa.state.pa.us. ECRI is an independent, nonprofit health services research agency dedicated to improving the safety, efficacy and cost-effectiveness of healthcare. ECRI’s focus is healthcare technology, healthcare risk and quality management and healthcare environmental management. ECRI provides information services and technical assistance to more than 5,000 hospitals, healthcare organizations, ministries of health, government and planning agencies, and other organizations worldwide. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP's efforts are built on a non-punitive approach and systems-based solutions. ©2006 Pennsylvania Patient Safety Authority Page 3