Patient death or disability resulting from a burn received while at a medical facility is a “never” event as defined by the National Quality Forum. Medicare has announced that it will not reimburse medical facilities for treatment required as the result of a burn obtained at that facility. Although there are many different ways a patient burn could occur, we will look at root causes for some of the more common situations that result in a patient burn.
Serious patient burns can result from exposure to hot equipment (typically an electrosurgical device placed on the patient) or from a surgical fire. A surgical fire, like all fires, requires three things to occur: an oxidizer, fuel, and an ignition source (or heat). In surgery, the oxidizer can be provided by atmospheric air, nitrous oxide, or an oxygen-enriched atmosphere. This leg of the fire triangle is typically controlled by an anesthesiologist.
There are many fuel sources in an operating room. Common operating room material, like drapes, gowns, sterile pads and gauze, is flammable under the right conditions, as are certain volatile prepping solutions and ointments, the patient’s hair, and body gases. Fuel sources are generally under the control of the nursing staff.
The most common ignition (heat) sources in the operating room are lasers and electrosurgical devices. These are generally controlled by the surgeon.
Because the three legs of the triangle are controlled by three different people in the operating room, good communication is essential. There are also some other operating procedures that reduce the risk of a fire. These solutions are shown in green boxes on the downloadable PDF.
Click on “Download PDF” above to download a PDF showing the Root Cause Analysis Investigation.
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