Reduction of Wrong-Limb Blood Pressure Cuff Placement Attempts With a High-Visibility Limb Alert Sleeve: A Randomized
Taylor Florio1, Gina Santosuosso2, Anthony Dardano3
1Plastic and Reconstructive Surgery, Larkin Community Hospital Palm Springs Campus, Hialeah, USA.
Cureus
|June 24, 2026
Summary
A high-visibility limb alert sleeve drastically reduced incorrect blood pressure (BP) cuff placement attempts in a simulation study. This simple visual cue improves patient safety by ensuring BP is measured on the correct limb.
Area of Science:
- Clinical Safety
- Patient Monitoring
- Medical Devices
Background:
- Wrong-limb blood pressure (BP) measurement is a common, preventable clinical error.
- Inconsistent adherence to limb restriction alerts in electronic medical records poses risks like fistula thrombosis and lymphedema.
- Chart review alone is insufficient for preventing errors in busy clinical settings.
Purpose of the Study:
- To evaluate if a high-visibility limb alert sleeve improves adherence to limb restrictions.
- To assess the sleeve's effectiveness in reducing wrong-limb BP cuff placement attempts.
Main Methods:
- A randomized, within-subject crossover simulation study with 50 clinical staff.
- Participants performed vital signs under chart-only and sleeve-present conditions.
- Primary outcome: rate of wrong-limb BP cuff placement attempts.
Main Results:
- Wrong-limb BP cuff placement attempts decreased from 60% (chart-only) to 2% (sleeve-present) (p < 0.0001).
- The limb alert sleeve resulted in a 58% absolute reduction in incorrect BP cuff placements.
- The single error in the sleeve condition was recognized and corrected before cuff inflation.
Conclusions:
- High-visibility limb alert sleeves significantly reduce wrong-limb BP cuff placement attempts.
- The sleeve provides a critical visual cue at the point of care, improving recognition of limb restrictions.
- Limb alert sleeves offer a practical strategy to prevent BP measurement errors in at-risk patients.
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Monitoring Both Arms:
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Monitoring Both Arms:
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Preparation:
Preparation:
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Prepare for the Procedure:
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