Patients over 65 account for 88% of all skin tears reported to the Patient Safety Authority, according to results of a recent study of 2,807 reports submitted by healthcare facilities to the Pennsylvania Patient Safety Reporting System (PA-PSRS). While most of these skin tears were not serious enough to extend a hospital stay, they represent painful and unsightly injuries for the patient, according to an article published in the September 2006 issue of the Patient Safety Advisory.

Reports submitted to PA-PSRS during the system's first full 12 months of mandatory statewide reporting (July 2004-June 2005) are consistent with studies in the clinical literature, which show the risk of skin tears increasing with age. The largest proportion of skin tear reports (41%) concern patients aged 75 to 84.

Treating a skin tear is also time consuming and painful for the patient. One report highlighted in the Advisory article describes a patient having to undergo stapling and stitches to treat a skin tear wound. Also, if changing the dressing for a skin tear is done incorrectly, further injury to the fragile wound may occur.

"The Authority chose to highlight the skin tear issue because of the high number of patients who experience these painful wounds, especially among older and more fragile populations," said Alan B.K. Rabinowitz, administrator of the Patient Safety Authority. "By providing clinical guidance about prevention and treatment of skin tears, we hope that healthcare facilities and providers will better understand the additional risks associated with skin tears and the number of ways these injuries can be prevented."

Some patient characteristics cited in the Advisory that often mean a patient's skin is more fragile and susceptible to tears include: advanced age (over age 70); malnourishment; vision/sensation/hearing loss; mental impairment; immobility; dry skin; and agitation or restlessness.

The Advisory article, entitled "Skin Tears: The Clinical Challenge," also includes several preventive measures. These include environmental assessments; educating staff, patient and family on the risks and preventive measures; adequate nutrition and hydration; and padding equipment especially when moving the patient. Proper technique when removing medical tape or adhesive dressings can also help to prevent skin tears.

In addition, the Authority is supplying healthcare facilities with a "Skin Tears Toolkit" to help them implement changes in their institutions to prevent these injuries.

The tool kit includes:

1) a single-topic reprint of the Skin Tears Advisory article;

2) a poster to remind clinicians about prevention and treatment of skin tears;

3) two sample policies on skin tears based on the guidance from the Advisory article; and 4) a brief, self-running slideshow with audio narration on safe practices related to skin tears, which can be downloaded and shown to front-line caregivers.

Other articles in the September 2006 Advisory provide analysis of the following events based on actual reports submitted to PA-PSRS by healthcare facilities in Pennsylvania:

-- Risks associated with MRI-incompatible sandbags: Some items labeled as "sandbags" may contain metal fragments, which can cause them to become airborne if they are used in or near an MRI. A Pennsylvania facility also wrote a "Letter to the Editor" describing their preventive efforts.

-- Taking a closer look at medical errors and why they happen: Often, the most obvious reason for a medical error is just the last in a series of events that together comprise the true cause. Most errors are caused by faulty systems that allow inevitable human errors to reach the patient-not bad healthcare providers.

-- The dangers associated with epinephrine: This high-alert drug can cause serious injury when used in error. The most frequently reported causes of errors involving this drug include: confusion over the drug concentration and confusion with ephedrine. Risk mitigation strategies are provided.

-- How to prevent pressure ulcers (i.e., bed sores): This article highlights the problems associated with bed sores and the ways healthcare facilities can prevent them, particularly in older patients who are most susceptible.

For a copy of the September 2006 Patient Safety Advisory, click here.

BACKGROUND

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 as amended, to help reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety. Under the Act, all Pennsylvania-licensed hospitals, birthing centers, ambulatory surgical facilities and certain abortion facilities are required to report what the Act defines as "serious events" and "incidents" to the Authority. More than 455 healthcare facilities are subject to Act 13 reporting requirements.

Facilities submit reports of serious events and incidents through the Pennsylvania Patient Safety Reporting System (PA-PSRS), a confidential web-based system that was developed for the Authority under a contract with ECRI, a Pennsylvania-based independent, non-profit health services research agency, in partnership with EDS, a leading international, information technology firm, and the Institute for Safe Medication Practices (ISMP), also a Pennsylvania-based, non-profit health research organization.

More than 380,000 reports have been submitted through PA-PSRS since the program was initiated in June 2004. Ninety-six percent of these reports are Incidents or "near-misses." Based on those reports, the Authority issues quarterly and supplementary Patient Safety Advisories to advise hospitals and other healthcare facilities about steps they can take to reduce and prevent patient harm.

The Authority has been named a recipient of the 2006 John M. Eisenberg Award for advancing patient safety and quality. Presented jointly by the Joint Commission on Accreditation of Healthcare Organizations and the National Quality Forum, the award acknowledges the Authority's impact on patient safety because of efforts to make the PA-PSRS system into a nationally recognized resource for education and learning about patient safety.

For more information on the Patient Safety Authority, PA-PSRS or previous Patient Safety Advisories, visit the Authority's website at psa.state.pa.us.

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