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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.<\/jats:p>","DOI":"10.1177\/1942602x221077234","type":"journal-article","created":{"date-parts":[[2022,2,12]],"date-time":"2022-02-12T00:32:21Z","timestamp":1644625941000},"page":"132-135","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Adverse Event Leads to Quality Improvement Plan: Learning From a Classroom Latex Exposure"],"prefix":"10.1177","volume":"37","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3598-3863","authenticated-orcid":false,"given":"Briana","family":"Posanka","sequence":"first","affiliation":[{"name":"Director of Continuing Nursing Education, Saint Anselm College, Manchester, NH"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"179","published-online":{"date-parts":[[2022,2,11]]},"reference":[{"key":"e_1_3_4_2_1","doi-asserted-by":"crossref","unstructured":"Beierwaltes P. Schoessler S. (2017). Latex safe at school: A student-centered approach. NASN School Nurse 32(6) 343-345. https:\/\/doi.org\/10.1177\/1942602X17715495","DOI":"10.1177\/1942602X17715495"},{"key":"e_1_3_4_3_1","doi-asserted-by":"crossref","unstructured":"Crane S. Sloane P. D. Elder N. Cohen L. Laughtenschlaeger N. Walsh K. Zimmerman S. (2015). Reporting and using near-miss events to improve patient safety in diverse primary care practices: A collaborative approach to learning from our mistakes. Journal of the American Board of Family Medicine 28(4) 452-460. https:\/\/doi.org\/10.3122\/jabfm.2015.04.140050","DOI":"10.3122\/jabfm.2015.04.140050"},{"key":"e_1_3_4_4_1","doi-asserted-by":"crossref","unstructured":"Kelly K. J. Sussman G. (2017). Latex allergy: Where are we now and how did we get there? 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Child mortality in the school setting (Position statement). https:\/\/www.nasn.org\/advocacy\/professional-practice-documents\/position-statements\/ps-child-mortality"},{"key":"e_1_3_4_8_1","unstructured":"National Association of School Nurses. (2018). The role of the 21st century school nurse (Position statement). https:\/\/www.nasn.org\/advocacy\/professional-practice-documents\/position-statements\/ps-role"},{"key":"e_1_3_4_9_1","doi-asserted-by":"crossref","unstructured":"Skinner L. Tripp T. R. Scouler D. Pechacek J. M. (2015). Partnerships with aviation: Promoting a culture of safety in health care. Creative Nursing 21(3) 179-185. https:\/\/doi.org\/10.1891\/1078-4535.21.3.17","DOI":"10.1891\/1078-4535.21.3.179"},{"key":"e_1_3_4_10_1","unstructured":"Spina Bifida Association. (2015). Latex in the home and community. https:\/\/www.spinabifidaassociation.org\/wp-content\/uploads\/latex-in-the-home-and-community-eng.pdf"},{"key":"e_1_3_4_11_1","unstructured":"U.S. Department of Health and Human Services. (n.d.). Spotlight on . . . adverse events. https:\/\/oig.hhs.gov\/newsroom\/spotlight\/2012\/adverse.asp#:~:text=Adverse%20Event%20%2D%20An%20event%2C%20preventable %2C%20permanent%20harm%2C%20or%20death"},{"key":"e_1_3_4_12_1","unstructured":"U.S. Food and Drug Administration. (2015). Don\u2019t be misled by \u201clatex free\u201d claims. https:\/\/www.fda.gov\/consumers\/consumer-updates\/dont-be-misled-latex-free-claims#:%7E:text=At%20this%20time%2C%20there%20are contain%20latex%E2%80%9D%20in%20their%20labeling"},{"key":"e_1_3_4_13_1","unstructured":"World Health Organization. (2005). 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