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:






Wozniacka G. The Associated Press. Oregon hospital patients burned by lights in operating rooms. CTV News. Published Thursday, January 22, 2015






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