Adverse Event Leads to Quality Improvement Plan: Learning From a Classroom Latex Exposure

Abstract

A growing number of students with health conditions, many of which carry with them the potential for an emergency, increases the likelihood of adverse events occurring in the school setting. An adverse event can be either preventable or nonpreventable. This article reviews a preventable adverse event which took place in a second-grade classroom of a student with spina bifida. Children with spina bifida are at increased risk for the development of latex allergy and subsequent anaphylaxis. The seriousness of accumulated exposure to latex necessitated initiation of a quality improvement plan with the goal of decreasing the risk of future exposures and increasing the quality of collaboration among school staff in meeting student health needs. The article describes the adverse event and discusses the five factors that were addressed in the quality improvement plan: communication deficit, knowledge deficit, hierarchical culture, product labeling, and data collection.