Patient Safety Authority Logo

Skip navigation links
HOME
PATIENT SAFETY AUTHORITYExpand PATIENT SAFETY AUTHORITY
PA-PSRS and PASSKEYExpand PA-PSRS and PASSKEY
PATIENT SAFETY ADVISORIESExpand PATIENT SAFETY ADVISORIES
PATIENTS AND CONSUMERSExpand PATIENTS AND CONSUMERS
NEWS AND INFORMATIONExpand NEWS AND INFORMATION
EDUCATIONAL TOOLSExpand EDUCATIONAL TOOLS
AUTHORITY EVENTSExpand AUTHORITY EVENTS







ADDRESS:
Patient Safety Authority
333 Market Street
Lobby Level
Harrisburg, PA 17120


Phone: 717-346-0469
Fax: 717-346-1090


  
Advisory Banner
Mix-up between Skin Prep Solution and Adhesive Remover
PA PSRS Patient Saf Advis 2006 Mar;3(1):29. 
 

PA-PSRS received two reports from one hospital describing a mix-up between skin prep solution and adhesive remover. A hospital staff member mistakenly used an adhesive remover on two patients instead of a skin prep solution prior to applying Holter monitor electrodes. Both events resulted in the patients experiencing erythematous skin reactions at the electrode sites.

The events occurred because the packaging for both the skin prep and adhesive remover are very similar in appearance (see Figure 1). The skin prep and adhesive remover are manufactured by Smith & Nephew, Inc. (Cat. Nos. 420400 and 403100, respectively) and have the same orange and white pattern with black lettering.

 Figure 1. Current Style of Packaging for Skin Prep and Adhesive Remover

  Figure 1. Current Style of Packaging for
  Skin Prep and Adhesive Remover 

 

 

 

 

The Smith & Nephew skin prep is a liquid prep solution used to prepare skin for tapes or similar adhesive items and also forms a film on skin to help reduce friction when those items are removed from the patient. The Smith & Nephew adhesive remover is used to soften the adhesives on items such as tapes and to remove adhesive residue.

In response to prior reports of the packages looking similar and in response to the events above, Smith & Nephew took steps to redesign the packaging for the skin prep and adhesive remover (see Figure 2). The front of the redesigned skin prep package now contains a green block of color containing the Cat. No. 420400, and the front of the redesigned adhesive remover package contains a maroon color containing the Cat. No. 403100. Both packages use a larger black font to distinguish one from the other. According 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.

 

Figure 2. New Style of Packaging for Skin Prep and Adhesive Remover

  Figure 2. New Style of Packaging for Skin Prep
  and Adhesive Remover

 

 

 

 

 

Healthcare facilities that use the above products can alert users to the information in this article, emphasizing the need to carefully scrutinize the packaging when obtaining either the skin prep solution or the adhesive remover. Until the newly designed packaging is available, consider providing signage or other identifiers near the products to alert users to the similar packaging of these products.
 
 Browse by Topic
go button Discipline
go button Audience
go button Care Setting
go button Event
go button Patient Safety Focus
go button Hospital-Acquired Condition
Print Page Print / Save PDF
Email to a Friend Email to a Friend
Editorial Information Editorial Information
Subscribe to Advisory Subscribe to the Advisories
Navigation  
Back to Advisory Issue

Article Sections
Mix-up between Skin Prep Solution and Adhesive Remover



THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS  
PSA LOGO The Pennsylvania 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 Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web site at www.patientsafetyauthority.org .      
ECRI LOGO ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.      

ISMP Logo 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 nonpunitive approach and systems-based solutions.      
 
©2012 Pennsylvania Patient Safety Authority                                                Home      Who We Are      Contact Us     Subscribe to Advisories and Press Releases   Site Map     Privacy Statement