BACKGROUND: The potential for skin damage from adhesive products is documented in the literature. Nevertheless, health care providers continue to lack understanding of the impact and seriousness of skin injury associated with use of tapes or other adhesive devices when applied to a patient with a history or hypersensitivity or allergy to adhesives. CASE: A 67-year-old woman with a history of tape allergy underwent emergency appendectomy. Initial removal of an adhesive bandage placed over the surgical incision revealed medical adhesive-related skin injury (MARSI). The largest of the 3 wounds was a Class III skin tear based on the Payne-Martin Classifi cation System. It measured (L) 4.4 cm × (W) 1.8 cm × (D) 0.3 cm and required 3 months to heal. CONCLUSIONS: Experiences with this case revealed the need for evidence-based practice innovations to prevent physical, emotional, and economic cost resulting from MARSI. We recommend early identifi cation and careful documentation of susceptibility to MARSI prior to surgery and implementation of consensus-based recommendations for prevention of MARSI as advocated by the MARSI consensus group when preparing patients for surgery and treating wounds.