Intended for healthcare professionals

Practice Safety Alerts

Reducing risks of tourniquets left on after finger and toe surgery: summary of a safety report from the National Patient Safety Agency

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1981 (Published 21 April 2010) Cite this as: BMJ 2010;340:c1981
  1. Tara Lamont, head of response1,
  2. Frances Watts, patient safety lead (surgery)1,
  3. John Stanley, consultant in hand and upper limb surgery2,
  4. John Scarpello, deputy medical director1,
  5. Sukhmeet Panesar, clinical adviser1
  1. 1National Reporting and Learning Service, National Patient Safety Agency, London W1T 5HD
  2. 2Wrightington Hospital Upper Limb Unit, Wigan WN6 9EP
  1. Correspondence to: T Lamont tara.lamont{at}npsa.nhs.uk

    Why read this summary?

    Tourniquets are used in hand and foot surgery because of the need for a bloodless field to allow for careful dissection. They are used in a range of settings, such as operating theatres, emergency departments, community sites (for example, for minor surgery in podiatry clinics). Although rare, complications can lead to serious harm, including, at worst, irreversible ischaemia.

    Between August 2005 and November 2009, healthcare staff in England and Wales reported 15 serious incidents in which tourniquets had been left on fingers or toes by mistake. Ten patients needed further surgery and two incidents resulted in amputation. At least six of the incidents related to surgical gloves being used as tourniquets. Fourteen litigation claims relating to tourniquets were also reported in this period.

    A typical incident report reads: “Patient had termination of tip of right ring finger. He attended plastic dressing clinic for routine follow up. When the dressing was removed, his ring finger was necrotic and still had what looked like a glove tourniquet in situ. Explained to patient he will require amputation.”

    In addition, two published case reports record amputations after retained tourniquets on fingers and toes.1 2

    This summary is based on a safety report (known as a “rapid response report” or “RRR”) from the National Patient Safety Agency (NPSA) on the risks of tourniquets left on fingers and toes, including use of gloves for this purpose, with key actions for staff.

    Problems identified by the National Patient Safety Agency

    Little good quality evidence exists to support different tourniquet techniques. The use of surgical gloves as tourniquets seems to be widespread as they are easily available and cheap, carry a low risk of infection, and are considered effective in achieving haemostasis. This practice is still recommended in manuals for emergency trainees and others.3 But gloves are normally flesh coloured and may inadvertently be left on. Some clinicians have advocated use of coloured gloves,4 and a widely cited paper by Smith and colleagues describes a modified technique using a glove and an artery clip.5 However, risks still remain (as acknowledged by Smith and colleagues) with this or any other “home made” device—for example, the risk of neuropraxia as pressure is applied in a very narrow area. The broad safety principle is that devices should be used for their intended purpose only.6

    The NPSA issued its RRR on the risks of tourniquets left on fingers and toes in December 2009 (NPSA/2009/RRR007, www.nrls.npsa.nhs.uk/tourniquets).

    What can we do?

    In the absence of evidence, the NPSA and the Royal College of Surgeons consulted clinical experts to identify key actions to make practice safer:

    • Use only tourniquets with the CE marking (which indicates conformity with the European Union’s safety standards), which are labelled and/or brightly coloured to maximise visibility. Do not use gloves as tourniquets

    • Reconcile the number of tourniquets through swab counting procedures, and record the on/off time of tourniquets

    • Consider including tourniquets as part of the surgical safety checklist (tourniquet removal at “sign out” stage)

    • Once the tourniquet has been removed, check for adequate perfusion of finger or toe

    • Ensure that staff and patients know to look for later signs of tissue ischaemia, necrosis, and gangrene (skin discoloration or a pulseless, painful, paralysed, paraesthetic, and cold digit).

    What else do we need to know?

    Responses from clinicians while the NPSA report was being compiled highlighted many items used as tourniquets, including catheters, elastic bands, and surgical gloves (either whole or finger only, sometime with additions—for example, artery clips or the red string used for bundling up gauze swabs). Some of these techniques may be safer than others, but little high quality evidence exists. However, the wide range of practice is in itself of interest and suggests the need for evidence based guidelines.

    How will we know when practice has become safer?

    Early information from the manufacturers currently producing tourniquets with the CE marking shows a 140% increase in purchasing in the three months after the issue of the RRR compared with a similar period before issue. The NPSA will continue to monitor purchasing. To date, no further incidents of harm from tourniquets left on after finger or toe surgery have been reported to the NPSA.

    Notes

    Cite this as: BMJ 2010;340:c1981

    Footnotes

    • This is one of a series of BMJ summaries of recommendations to improve patients’ safety, based on reports of safety concerns, incident analysis, and other evidence. The articles will highlight the risks of incidents that have the potential for serious harm and are not well known, and for which clear preventive actions are available.

    • To report adverse events to the National Patient Safety Agency, go to www.nrls.npsa.nhs.uk/

    • Contributors: TL wrote the first draft, based on work led by FW and others at NPSA (with input from J Stanley. All authors reviewed the draft. TL is the guarantor.

    • Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author and declare (1) No financial support for the submitted work from anyone other than their employer; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; (4) No non-financial interests that may be relevant to the submitted work.

    • Provenance and peer review: Commissioned; not externally peer reviewed.

    References

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