HospitalInspections.org

Based on a review of clinical records, interview with hospital personnel and review of hospital documentation and/or policies, for one (Pt# 310) of ten patients reviewed, the hospital failed to ensure that a sponge utilized during surgery was moistened when used in the presence of electrocautery equipment in accordance with hospital policy. The finding includes:
Patient #310 was admitted to the hospital on 5/10/11 with diagnoses that included hypertension, coronary artery disease, angina and emphysema. Review of the operative report dated 5/10/11 identified that Patient #310 underwent an off pump coronary artery bypass x 4. The report identified that while the surgeon pursued hemostasis along the mammary bed, the lap pad utilized to protect the lung during this process caught fire from the cautery equipment. Immediately recognized, the lap pad was tossed away from the patient where it was doused in saline. The operative report identified that the patient received a thermal injury approximately 2 cm in length on the left upper lobe of the lung. Postoperatively, the patient was extubated, seen by a pulmonologist and ultimately discharged.
During interview on 5/13/11, PA #4, who assisted MD #103 (surgeon), stated that the lap pad, under the surgeon's left hand, was observed as glowing orange and PA #4 stated "the lap pad is on fire" as the surgeon simultaneously threw the lap pad onto the floor.
During interview on 5/13/11, MD #103 stated that he/she could feel heat to the left side of his/her left hand when PA #4 stated the pad was on fire. MD #103 immediately threw the pad to the floor. MD #103 stated that he/she was aware that the lap pad should be moist when working adjacent to electrocautery and questioned if the pad he/she had utilized was dry. MD #103 failed to request and receive a moistened lap pad from Surgical Tech (ST) #1.
During interview on 5/17/11, ST #1 stated that MD #103 picked up a dry lap pad from the sterile field which MD #103 utilized while using the electrocautery unit. ST #1 stated that although the usual practice was to hand moist pads to the surgeon, she had turned away to complete a count and had not given the lap pad to the surgeon.
Review of hospital fire education/policies relative to fire in the OR identified that prevention of surgical fires included using moistened sponge material around the surgical site when using electrocautery equipment. The hospital failed to ensure that moistened sponge material was utilized at all times within proximity of electrosurgical equipment according to hospital policy.
The hospital immediately reeducated the Operating Room staff and MD #103 to the prevention of surgical fires policy with a plan to educate all staff pertaining to this policy. The hospital identified that they would also review and revise the fire risk assessment policy and initiate operating room audits to monitor compliance.