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 Burn” of
things your organization should you do to minimize the risks of iatrogenic
burns:
- Do an inventory or survey
in your organization to see if you use “warm compresses” or heat therapy
(if you have computerized order entry you might be able to find these
orders. Otherwise you’ll have to just survey nurses and doctors to see if
they are ever used at your organization).
- If you find warm
compresses are being used, make sure there is a good clinical evidence
base to support their use for that particular indication.
- Establish burn risk
assessments
It’s not likely to be good use of time doing universal burn risk assessment on admission. Rather, you need to identify in which patients and when burn risk assessments should be done. Obviously that would be in any patient in whom use of heat is contemplated. The assessment would include whether the patient has the ability to perceive pain and temperature in the site(s) where heat is to be applied. - In your neonatal units,
make sure you have protocols in place for assessment of temperature of any
object that may come into contact with the skin
of an infant and any other heat sources (eg.
lights) that may be close to the infant.
- If you apply heat, have
protocols that require assessment of temperature and specify intervals at
which skin assessment must be done.
- In the OR, beware of the
burn danger any time a “flashed” piece of equipment is used and have a
system to ensure such instruments have adequately cooled before use.
- Better yet, optimize your
equipment/instrument inventory and practices so that you don’t every need
to “flash” sterilize items.
- In the MRI suite, your
protocols must include steps to identify any wires or cables that cannot
be removed and ensure that there is minimal “coiling” or “looping” of
these. Also make sure the patient is not wearing any transdermal drug
patches that might contain metal or ferromagnetic components. (But also don’t forget after the scan is completed to
restore the cables or drug patches.)
- See the recommendations in
our December 23, 2014 Patient
Safety Tip of the Week “Iatrogenic
Burns in the News Again” regarding use of warming devices.
- See the recommendations in
our October 5, 2010 Patient Safety Tip of the Week “More
Iatrogenic Burns” regarding use of dental handpieces.
- Heed the advice in our September 5, 2017 Patient Safety Tip of
the Week “Another
Iatrogenic Burn”
regarding steps to minimize the risk of burns related to electrocautery
devices and operating microscopes.
And Field’s recommendations:
- Maintain hot tap water at
appropriate temperatures to prevent scald burns.
- Maintain warming and
solution cabinets at recommended temperatures.
- Implement policies for use
of instant hot water dispensers and microwave ovens, based on the patient population
and specifications of the devices.
- Implement policies for
serving food and beverages at safe temperatures.
- Provide tableware designed
to prevent spillage.
- Educate dietary services
staff on the safe preparation and delivery of heated beverages and food.
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:
- March 2009 “Risk
of Burns during MRI Scans from Transdermal Drug Patches”
- June 1, 2010 “Iatrogenic
Burns”
- October 5, 2010 “More
Iatrogenic Burns”
- December 23, 2014 “Iatrogenic
Burns in the News Again”
- March 2015 “Another
Source of Iatrogenic Burns”
- September 5, 2017 “Another
Iatrogenic Burn”
References:
Field C. Hot Topic: Nonsurgical, Healthcare-Associated Burn
Injuries. Pa Patient Saf Advis
2018; 15(1).
http://patientsafety.pa.gov/ADVISORIES/Pages/201803_BurnInjuries.aspx
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