Patient Safety Tip of the Week

June 5, 2018

Pennsylvania Patient Safety Authority on Iatrogenic Burns



Our past columns on iatrogenic burns have had a heavy focus on surgery-related things like burns related to instruments that had been flash sterilized and inadequately cooled prior to use or related to use of electrocautery devices.


But the Pennsylvania Patient Safety Authority recently published an excellent advisory focusing on iatrogenic burns unrelated to surgery (Field 2018). Cynthia Field analyzed burn events reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) in 2016 and found that over 60% occurred in non-surgical settings.


To our surprise, the most frequent thermal burns involved dietary spills of heated drinks or food (53 of their 107 non-surgical iatrogenic burns or 49.5%). Examples included spilled hot soup, coffee, and tea but microwaved foods were also mentioned.


Heating devices were the second most frequent culprits (30.8%). These included warm compresses and hot packs and powered devices such as circulating water or air blankets.


The third most frequent items associated with non-surgical iatrogenic burns related to MRI imaging. The report did not break down the nature of burns associated with MRI but we’ve discussed these before. Any ferromagnetic device can overheat when exposed to the magnetic forces of the MRI unit. That is why patients are questioned and examined for presence of such devices. Probably the most overlooked ones are transdermal drug patches that contain metal (see our March 2009 What's New in the Patient Safety World column “Risk of Burns during MRI Scans from Transdermal Drug Patches”). Others have involved wires on monitoring devices, particularly when coiled or looped.


And burns were also seen from defibrillator paddles, chemicals (irritant or caustic substances), and various electrodes or monitoring devices. There were also 6 cases related to ultraviolet light therapy and a smattering of other causes.


Field highlights our frequent point that burns are a function of not only temperature but also duration of exposure. The classic example is the flash sterilized tool that is warm to the touch, but when placed on the drapes over a patient’s abdomen in the OR, leads to a dermal burn. And she also notes our warnings that patients with impaired sensation are especially vulnerable to iatrogenic burns and those with impaired ability to communicate (eg. aphasia, dementia, etc.) may not be able to convey when they are in pain from an impending burn.


So we’ll add some of Field’s recommendations to the list from our September 5, 2017 Patient Safety Tip of the Week “Another Iatrogenic Burnof things your organization should you do to minimize the risks of iatrogenic burns:


And Field’s recommendations:


The PPSA Advisory by Field is an important contribution to the relatively scant literature on iatrogenic burns in healthcare, It especially draws attention to the risks of food and beverages that have largely been ignored in the past. We obviously need to pay more attention not only to the temperature of foods and beverages but also to the likelihood that they might be spilled onto the patient due to patient-related factors or environmental factors.



Our prior columns on iatrogenic burns:







Field C. Hot Topic: Nonsurgical, Healthcare-Associated Burn Injuries. Pa Patient Saf Advis 2018; 15(1).





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