Recently I visited a friend in the hospital who just had surgery. During our visit the nurse came in to remove the tape on his abdomen resulting in a skin tear. The look on his face was extremely painful.
This brought back memories from a few years ago when I worked a project to reduce the number of skin tears in a hospital. Skin tears are one of the most common forms of injury, no doubt thanks to the sheer number of causes. These tears actually occur when the skin, or dermis, begins to separate from itself, an especially painful experience that can lead to infection if the damaged area remains untreated.
After collecting data on causes of skin tears, we found that tears due to adhesives occurred the most often in surgical services and inpatient units. With further root cause analysis we found the optimal solution – changing the type of tape that was used after surgery and in the inpatient units.
I go back to my friend’s injury and know it could have been prevented! Why does this hospital continue to use tape that causes skin tears?
The point of this blog isn’t to discuss skin tears or how to prevent skin tears but to discuss the missing components needed in our healthcare systems to enable communication of information to prevent painful patient safety events.
Awareness: Did we even know skin tears are a patient safety event? Through many photos and examples we began to build an awareness of not only what a skin tear is and how often it happens, but that it is not acceptable for our patients to feel this kind of pain. Many of the comments we received from clinical staff were along “Surgery is painful. This is just part of the process”. There seemed to be an overall acceptance that it can’t be prevented or that there are bigger issues that require attention first. Never the case. We should always do our best to manage the patient’s pain.
Bringing in insiders and outsiders to help: By including others in the analysis and solutions phase of the project, we quickly saw other options we had not considered. We brought in the 3M representatives to meet with the nurses and physicians. Immediately the representative identified a new kind of tape that used silicone and does not adhere to the skin in such a way that causes skin tears. Of course everyone was skeptical at first which leads us to the third point.
Asking the right questions: We started talking to others in the hospital outside of our group. A new set of eyes can bring different pieces of the puzzle together. A person in the purchasing department was at our presentation and raised their hand saying, “We already buy the silicone tape, we purchase it for surgical services.” An Anesthesiologist quickly replied, “Yes! We use that on our patients when securing the trach and it works wonders for our patients. There is no irritation or tears on their face.” Bingo proof it works in the clinical environment. The tape does hold. If we didn’t communicate outside of our group we might have never found this solution.
Status quo has to go – pilot and experiment: The entire group had a mental block to new solutions because they did not want to take any chances. Even though the anesthesiology department utilized the tape, people still struggled to shake their old mental mind maps. So we decided to pilot the new tape in strategic areas of the inpatient unit and surgical services department. The more success we had in reducing skin tears the more acceptance there was for using the different kind of tape.
Skin tears represent the change we know is needed but are too scared to try. Many organizations, particularly healthcare, are reluctant to communicate with others outside their organization or industry. Many of the answers that we need in today’s complex world come from involving others outside of our immediate circle of influence. It takes brave leaders to develop systems and structures that allow employees to reach out and communicate with others. It’s important for employees to be included in the problem solving process for sustainability. It can be scary to “air the proverbial dirty laundry” but can also be very rewarding.