What’s New in the Patient Safety World
March 2015
Another Source of Iatrogenic Burns
We’re always amazed
at the varied circumstances in which hospitalized patients may suffer
iatrogenic burns. While we’ve mentioned heat from light sources such as fiberoptic light as a potential heat source for OR fires
(see our December 4, 2007 Patient Safety Tip of the Week “Surgical
Fires”), we have not discussed
light sources in other iatrogenic burns.
Now halogen lights have been identified as the cause for
burns of multiple patients in operating rooms at an Oregon hospital (Wozniacka
2015). The report says that about 10 patients, possibly more,
suffered burns over a period of several months. The hospital director of quality and risk services was
quoted as saying the hospital initially “looked at more common culprits:
solutions used to prep skin before surgery, bandages or dressings used after
surgery, and cautery devices used to stop bleeding during surgery”. It was only
later that a surgery team member recalled maintenance had been done on the OR
lights. Apparently halogen lamps require filters for UV light and those
were not changed at the time of maintenance. Subsequently, the hospital has
switched to light-emitting diodes (LED’s) and it has changed procedures for
medical equipment maintenance, requiring the engineering department or the
equipment's vendor to do any kind of maintenance.
Sometimes causes for
unusual events are not readily apparent. But it sure helps to disseminate such
lessons so another facility won’t need months to solve the problem.
Our prior columns on iatrogenic burns:
- June 1, 2010 “Iatrogenic Burns”
- October 5, 2010 “More Iatrogenic Burns”
- December 23, 2014 “Iatrogenic
Burns in the News Again”
References:
Wozniacka G. The Associated Press. Oregon hospital patients burned by lights in operating rooms. CTV News. Published Thursday, January 22, 2015
http://www.ctvnews.ca/health/oregon-hospital-patients-burned-by-lights-in-operating-rooms-1.2200261
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