Pennsylvania Patient Safety Advisory Tubular Dressing Retainer: Retention without Restriction ABSTRACT and [patient was] released. [The patient] returned for Tubular dressing retainers are commonly used to apply dressing being wrapped too tight. The wound assess- and hold dressings, creams, and other devices in ment identified the wound to be healing satisfactorily. place. However, improper application of the retainer The finger was dressed with the wrong dressing size; and use of incorrect size, especially on digits, has tubular dressing retainer size 1 had been used as the caused harm to patients. Injury can occur if the tubu- dressing. [emphasis added] It was meant to be used as lar dressing retainer is mistakenly used as the gauze a single strip to hold the actual dressing in place. The dressing, especially if multiple layers are applied with area [appeared necrotic], requiring amputation of the multiple turns. Since June 2004, PA-PSRS has received finger tip. two reports indicating circulatory compromise to digits with tubular dressing retainer application. Additionally, The patient [was seen in] the ED for cuts on two fin- the U.S. Food and Drug Administration’s Manufac- gers. [Patient] presented again [a few] days later with turer and User Facility Device Experience (MAUDE) impaired vascular status of digits. The wrong dressing database revealed events of vascular complications was used: tubular dressing retainer size 1. This was following application of tubular retention dressings on meant to be a single strip to hold the actual dressing digits including the thumb. Although a small number in place; instead, it was used as the dressing. It got of cases were reported in the MAUDE and PA-PSRS tighter with each successive application and turn of databases, the events described indicated significant the metal ring. The patient was referred to a plastic harm to patients, including amputation of digits. Facili- hand [specialist] for surgery. The patient is currently ties may reduce harm to patients by implementing undergoing physical therapy. processes to improve the safety of tubular retention MAUDE dressings. An inventory of tubular dressing retainers in a facility can help target strategies to be implemented. A search of the MAUDE database using the keyword Education for physicians, nurses, and other healthcare search term “tubular dressing retainer” revealed five providers involved in the application of these dress- reports between 1992 and 1998 describing events of ings is essential. Patient education and instructions vascular complications following application of tubu- regarding these dressings are necessary to reduce lar dressing retainers on digits including the thumb. harm. (Pa Patient Saf Advis 2008 Dec;5[4]:127-9.) Similar to the PA-PSRS reports, the MAUDE reports describe patients complaining of increased pain dur- ing a two-to-three-day period after application of the dressing retainer. Removal of the dressing and reas- sessment of the wound did not occur until several days Improper application and use of the incorrect tubular after the dressing was applied, despite early onset of dressing retainer size can cause significant harm to pain. Vascular compromise was identified during reas- patients. A review of the PA-PSRS and U.S. Food sessment, and symptoms ranged from discoloration of and Drug Administration’s Manufacturer and User the digit to permanent disability and, in some cases, Facility Device Experience (MAUDE) databases identi- amputation of the digit. fied cases of circulatory compromise associated with application of these dressing retainers. The reports Dressing Retainers identified in the databases described patients experi- Dressing retainers are a valuable tool for wound care encing increased pain after application of the dressing procedures. They are made of conforming, hypoaller- and failure to seek further medical treatment, resulting genic, nonlatex, elastic material. The dressing retainers in amputation of digits. Dressing retainers must be have built-in windows that afford a view of the primary used properly for safe, high-quality patient care. dressing and are available in a variety of sizes adjusted Reports of Patient Harm Associated with Use of to the circumference of different body parts.1-3 Tubular Dressing Retainers Tubular dressing retainers are easy to apply and PA-PSRS remove. When properly applied, they are convenient and conform well to the shape of the bandaged part. Since June 2004, PA-PSRS has received two reports When the proper size is used, they are comfortable for indicating problems with tubular dressing retainers. the patient.1 Dressing retainers are designed to keep The reports indicated that the patient’s circulation dressings, creams, intravenous lines, and devices (e.g. was compromised due to use of incorrect size and splints) in place without causing discomfort to the improper application of the dressing. The reports patient. Tubular dressing retainers are to be applied below illustrate harm to patients. in a single layer; they are not to be used as the tubular [Patient] came to the emergency department (ED) dressing itself. Retention dressings eliminate the need for laceration of finger. [The laceration was] treated for adhesive tape, which is a benefit for patients who Vol. 5, No. 4—December 2008 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Page 127 Pennsylvania Patient Safety Advisory have friable or sensitive skin.3 Tubular dressing retain- managers can assess type and sizes of tubular reten- ers should not be used to apply pressure or be applied tion dressings stocked in their area. An inventory can to edematous limbs. Dressing retainers are made prompt managers to reevaluate the use of retention of elastic, which does not provide compression but dressings and assess the appropriate sizes to stock. secures dressings. They do not provide support and Establishing adequate stock and assigning appropri- will not help in shifting fluid.2 ate staff to ensure that adequate supplies are available can reduce the risk of staff using the incorrect size. Circulatory Compromise Additionally, with multidisciplinary input, facilities A literature search revealed a limited number of can determine which departments are appropriate to articles and cases associated with tubular dressing stock the dressings and to provide education to all retainers. Events involving these dressings appear staff applying the dressings. infrequently in the literature and reporting systems, Staff education involves all healthcare providers using yet there is potential for significant harm to patients the dressings. A small reminder card may be attached (i.e., compromised circulation requiring amputation). to the tubular dressing retainer box, clearly posted in Circulatory compromise has been attributed to using the storage areas where the dressings are located, and/ the incorrect size and improper application of tubular or can be easily carried by practitioners who use these retention dressings onto digits.1,4 Complications are dressings (see “Accompanying Patient Safety Tool”). the result of a tourniquet-type effect and occur due to application of the incorrect size, application of too Include the following points when educating staff: many layers, and rolling or bunching of dressing elas- ■ Choose the appropriate size for the anatomical tic. Rolling occurs when the edges of the dressing roll area.1,2,4 together to form a constricting ring. Bunching occurs ■ Because manufacturers’ recommendations may not when the dressing bunches at the base of digits to pro- always be reliable, use clinical judgment and com- duce a tourniquet effect.1,2,4 mon sense when choosing the appropriate size.4 Complications include the following:4 ■ Apply only one layer of tubular dressing retainer to ■ Pain secure the dressing over the wound.1 ■ Edema ■ Apply retention bandages from joint to joint to ■ Cyanosis prevent tightness and discomfort.2 ■ Provide healthcare workers the opportunity to ■ Necrosis practice applying the dressing to different anatomi- ■ Amputation of digits cal areas on each other. Risk Reduction Strategies ■ Require an annual retraining for staff applying Facilities may reduce harm to patients by implement- tubular dressing retainers. ing processes to improve the safe use and application (Refer to the Figure for correct application of tubular of tubular dressing retainers. Proficient bandaging dressing retainers.) skills are essential to reduce the risk of increased dis- comfort and pain or further injury.2 Facilities should Figure. Correct Application of Tubular Dressing check the type of tubular dressing retainers stocked Retainer and used within the hospital. Education for physi- cians, nurses, and other healthcare providers involved in the application of these dressings should include correct application and awareness of the mechanisms that may result in complications. Finally, patient edu- cation and instructions regarding these dressings are necessary to reduce harm. Inventory assessment is conducted to identify the avail- ability of tubular dressing retainers and to determine what departments use the dressing. Department Accompanying Patient Safety Tool Visit the Pennsylvania Patient Safety Authority Web site to view or obtain “Tips for Application of Tubular Dressing Retainer,” a quick reference card based on this article that can be carried by prac- titioners who apply tubular dressings or kept with the materials. Reprinted with permission. Page 128 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Vol. 5, No. 4—December 2008 Pennsylvania Patient Safety Advisory Patient education is a fundamental component to pre- promotes healing and provides patient comfort. How- vent harm from retention dressings. The majority of ever, when these dressings are applied inappropriately, patients with tubular retention dressings are cared for they can cause significant harm to patients. Proper in an outpatient setting. Patients will need to be made education to healthcare workers and understandable aware of signs and symptoms of problems and what instructions to patients are strategies facilities may to do if they occur. The following points are pertinent implement to reduce the risk of harm to patients. for written instructions provided to the patient: Notes ■ Elevate the bandaged extremity above heart level for the first 24 hours to decrease swelling.1 1. Yaffe B, Shafir R. Complication with the elastic tubed net bandage. Orthop Rev 1986 Aug;15(8):115-6. ■ Examine exposed skin surrounding the retention dressing for color and temperature.1 2. Baxter H, Ballard K. Bandaging: a vital skill. Nurs Times 2001 Jul 12-18;97(28):56-61. ■ Remove tubular dressing immediately in response to increased pain, and seek emergency care.1 3. Fraser K. Evaluation of Acti-Wrap: a new cohesive reten- tion bandage. Br J Nurs 2002 Nov 14-27;11(20):1341-4. Tubular dressing retainers provide an easy method to secure nonadhesive dressings, especially on difficult 4. Giandoni MB, Vinson RP, Grabski WJ. Ischemic com- anatomical areas such as digits, chins, knees, and plications of tubular gauze dressings. Dermatol Surg 1995 elbows. When properly applied, the dressing retainer Aug;21(8):716-8. Vol. 5, No. 4—December 2008 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Page 129 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 5, No. 4—December 2008. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority as part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). Copyright 2008 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to https://www.papsrs.state.pa.us/ Workflow/MailingListAddition.aspx. To see other articles or issues of the Advisory, visit our Web site at http://www.patientsafetyauthority.org. Click on “Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS 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 PA-PSRS program, 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 PA-PSRS program or the Pennsylvania Patient Safety An Independent Agency of the Commonwealth of Pennsylvania Authority, see the Authority’s Web site at http://www.patientsafetyauthority.org. 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 nearly 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. 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.