HospitalInspections.org

Based on review of facility documents, review of medical records (MR), review of credential files (CF), review of personnel files (PF), and staff interview (EMP), it was determined the facility failed to ensure staff working in the operating room were educated in the use of surgical skin preparations that contain combustible agents.
Findings include:
Review on April 20, 2022, of facility policy, "Fire Prevention and Patient Fire Risk Assessment," revised January 2021, revealed "I. Purpose: To provide guidance to perioperative personnel in preventing fires during surgical and other invasive procedures and responding appropriately if a fire should occur. II. Policy: Members of the perioperative team are responsible for preventing fires in the surgical environment and for participating in annual department fire safety education. Fire safety education will occur for staff annually, and may include but not limited to participating in department mock drills, identification of evacuation routes, participation in fire extinguishing techniques, and identification of medical gas and electrical panel shut off. ..."
Review on April 20, 2022, of MR1 revealed MR1 was a 60-year-old patient who presented to the facility on April 15, 2022, for an outpatient surgical procedure. There was documentation MR1 was scheduled for the removal of three scalp lesions. There was physician documentation MR1 was oxygen dependent at home and required oxygen via face mask for the surgical procedure. There was surgeon documentation MR1 was brought to the OR and sedated. There was documentation the site was prepped and draped in sterile fashion. There was documentation the time out and fire risk assessment was completed. There was documentation MR1 was a level four, highest risk of fire.

Continued review of MR1 revealed local anesthesia was administered to the lesion near the front of the hairline. A two-centimeter incision was made, and a small vessel was cauterized. The cautery ignited the hair and fire spread to the drape. The drape was taken off and the fire was extinguished with lactated ringers (LR). The scalp was rinsed with LR. The patient was further sedated, intubated, and bronchoscopy was performed to evaluate airway. There was no evidence of airway injury, but the endotracheal tube was left in place as a precaution. MR1's face was cleaned and debrided with saline and hibiclens and betadine were applied. The surgical site was cleaned, sutured, and covered in betadine. MR1 was transferred to ICU and plastic surgery was consulted.

Continued review of MR1 revealed a plastic surgeon saw the patient on April 15, 2022, at approximately 1250. There was documentation MR1 was recommended to transfer to a burn center for second degree burns to face. There was documentation MR1 had findings consistent for upper airway burn to nose, eyelids, and would require further evaluation by ophthalmology for possible ocular injury. There was documentation MR1 was transferred to tertiary care burn center at approximately 1430.

Review on April 20, 2022, of PF3 revealed PF3 started at the facility in the operating room on January 17, 2022. There was no education regarding the use of surgical skin preparations that contain combustible agents prior to PF3 starting in the operating room.
Interview on April 20, 2022, with EMP1, at approximately 1100, confirmed PF3 started at the facility in the operating room on January 17, 2022, and there was no education regarding the use of surgical skin preparation that contain combustible agents prior to PF3 starting in the operating room.
Review on April 20, 2022, of CF3, revealed CF3 had a privilege date of December 22, 2021. There was no education regarding the use of surgical skin preparation that contain combustible agents and CF3 was currently working in the operating room.
Interview on April 20, 2022, with EMP1, at approximately 1115, confirmed CF3 had a privilege date of December 22, 2021. There was no education regarding the use of surgical skin preparation that contain combustible agents and CF3 was currently working in the operating room.