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Based on interviews with the OR staff, and a review of the Safe Environment of Care plan, the facility failed to properly follow the procedures outlined in the Safe Environment of Care Plan by not allowing the Clora Prep solution to completely dry, and by not properly arranging the surgical drapes for a surgical procedure where oxygen was being administered to a surgical patient in accordance with 1999 edition of NFPA 99, Standard for Health Care Facilities 2-2, 7-6.2.4.1, 8-2.1.2.1, 8-2.1.2.2,8-2.1.1.4(a), 8-2.1.4(d), 8-2.1.1.2 and 9-2.1.9.3. This deficient practice could affect 5 of the 70 patients.

Findings include:

That on February 15, 2012, at 12:00 PM, a biopsy surgical procedure was performed in Operating Room 2 on "patient #1", and that the patient did suffer a thumb and superficial facial burn injuries as outlined below.

The information below is based on interviews with all five of the Operating Room staff that were present during the procedure, a review of available facility records, and an inspection of the surgical items that were used during this procedure.

The temporal arterial biopsy surgical procedure was being performed on the side of the patient 's face. The patient was lying on his back. His head was supported by a soft, gel headrest, approximately 3 inches thick and 7 inches in circumference. For this procedure oxygen, at the rate of approximately 8 liters per minute was being provided to the patient via a plastic mask, with a 1/4" plastic supply tube to the plastic mask. Clora Prep, an alcohol based preparation, was applied to the area of the patient's temporal area, but staff waited only one minute for the solution to completely dry. A surgical drape was placed over the patient's chest area and around the patient's face with the facial area open from the eyes to the mouth area with an opening to do the surgical procedure. An electrical cauterization device was also being used.

During the procedure a flash fire, apparently ignited by the cauterization device, started just above the site of the surgical procedure at the patient 's temporal hair line and spread to the patient's plastic oxygen mask causing it to burn. The (flash) fire also went under the surgical drape, around the patient 's head and neck area, burning portions of the drape and several inches of the supply tube providing oxygen to the patient.

The surgeon and staff immediately began patting the patient's facial, head and chest area to extinguish the fire. Staff shut off the oxygen and opened a bottle of saline solution and poured it over the patient's head and chest area. The operating room staff notified the hospital's response unit staff. The response unit staff came to operating room and the patient was then transferred to Regions Hospital, but was release before receiving treatment.

The patient received what appeared to be 2nd degree burns to his thumb and some minor superficial burns to the face area.

On February 17, 2012 at 12:30 PM, a reconstruction of the incident was done. A review of the patient placement, gel pad headrest, and surgical drapes were set up as normal for a procedure of this type and a review of all medical equipment and patient clothing articles that were actually involved in the fire were examined.

During the incident reconstruction it was noted that the distance between the plastic oxygen mask on the patient's nose /mouth and the biopsy site on the patient's face was approximately 4-5 inches. The biopsy site was within the 12 inch radius of the oxygen-enriched atmosphere "site of intentional expulsion" as defined in Chapter 2-2, Definitions, NFPA 99, 1999 Edition, Standard for Health Care Facilities.


As a result of the incident reconstruction process on February 17, 2012 at 12:30 PM, and a review of the Safe Environment of Care plan, it was determined that the facility failed to follow the hospital's surgical policy procedures as noted below:

1. The surgical staff failed to provide adequate time for the flammable surgical prep solution to dry completely, and to allow any fumes to dissipate before applying the surgical drapes, using an active electrode, or laser, or activating a fiber-optic light cable.

2. The surgical staff applied the surgical drapes too quickly to prevent the accumulation of volatile fumes beneath the drapes. Surgical drapes are not be applied until the prep solutions are allowed to completely dry.

3. The surgical staff failed to take proper precautions, as outlined in the Safe Environment of Care Plan, when electrosurgical devices and/or lasers are used when oxygen is flowing.

Based on interviews with the OR staff, and a review of the Safe Environment of Care plan, the facility failed to properly follow the procedures outlined in the Safe Environment of Care Plan by not allowing the Clora Prep solution to completely dry, and by not properly arranging the surgical drapes for a surgical procedure where oxygen was being administered to a surgical patient in accordance with 1999 edition of NFPA 99, Standard for Health Care Facilities 2-2, 7-6.2.4.1, 8-2.1.2.1, 8-2.1.2.2,8-2.1.1.4(a), 8-2.1.4(d), 8-2.1.1.2 and 9-2.1.9.3. This deficient practice could affect 5 of the 70 patients.

Findings include:

That on February 15, 2012, at 12:00 PM, a biopsy surgical procedure was performed in Operating Room 2 on "patient #1", and that the patient did suffer a thumb and superficial facial burn injuries as outlined below.

The information below is based on interviews with all five of the Operating Room staff that were present during the procedure, a review of available facility records, and an inspection of the surgical items that were used during this procedure.

The temporal arterial biopsy surgical procedure was being performed on the side of the patient 's face. The patient was lying on his back. His head was supported by a soft, gel headrest, approximately 3 inches thick and 7 inches in circumference. For this procedure oxygen, at the rate of approximately 8 liters per minute was being provided to the patient via a plastic mask, with a 1/4" plastic supply tube to the plastic mask. Clora Prep, an alcohol based preparation, was applied to the area of the patient's temporal area, but staff waited only one minute for the solution to completely dry. A surgical drape was placed over the patient's chest area and around the patient's face with the facial area open from the eyes to the mouth area with an opening to do the surgical procedure. An electrical cauterization device was also being used.

During the procedure a flash fire, apparently ignited by the cauterization device, started just above the site of the surgical procedure at the patient 's temporal hair line and spread to the patient's plastic oxygen mask causing it to burn. The (flash) fire also went under the surgical drape, around the patient 's head and neck area, burning portions of the drape and several inches of the supply tube providing oxygen to the patient.

The surgeon and staff immediately began patting the patient's facial, head and chest area to extinguish the fire. Staff shut off the oxygen and opened a bottle of saline solution and poured it over the patient's head and chest area. The operating room staff notified the hospital's response unit staff. The response unit staff came to operating room and the patient was then transferred to Regions Hospital, but was release before receiving treatment.

The patient received what appeared to be 2nd degree burns to his thumb and some minor superficial burns to the face area.

On February 17, 2012 at 12:30 PM, a reconstruction of the incident was done. A review of the patient placement, gel pad headrest, and surgical drapes were set up as normal for a procedure of this type and a review of all medical equipment and patient clothing articles that were actually involved in the fire were examined.

During the incident reconstruction it was noted that the distance between the plastic oxygen mask on the patient's nose /mouth and the biopsy site on the patient's face was approximately 4-5 inches. The biopsy site was within the 12 inch radius of the oxygen-enriched atmosphere "site of intentional expulsion" as defined in Chapter 2-2, Definitions, NFPA 99, 1999 Edition, Standard for Health Care Facilities.


As a result of the incident reconstruction process on February 17, 2012 at 12:30 PM, and a review of the Safe Environment of Care plan, it was determined that the facility failed to follow the hospital's surgical policy procedures as noted below:

1. The surgical staff failed to provide adequate time for the flammable surgical prep solution to dry completely, and to allow any fumes to dissipate before applying the surgical drapes, using an active electrode, or laser, or activating a fiber-optic light cable.

2. The surgical staff applied the surgical drapes too quickly to prevent the accumulation of volatile fumes beneath the drapes. Surgical drapes are not be applied until the prep solutions are allowed to completely dry.

3. The surgical staff failed to take proper precautions, as outlined in the Safe Environment of Care Plan, when electrosurgical devices and/or lasers are used when oxygen is flowing.