HospitalInspections.org

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Based on record review and interview the facility failed to conduct inspections for electrical equipment that was brought in by an outside source. Specifically, the facility failed to ensure lithium batteries brought in from an outside source and used in a dentist's personal headlamp was checked for safety by a biomedical technician. Failure to ensure the equipment was inspected resulted in a fire in the operating room (OR) and had the potential to injure 1 patient who was in the OR. Findings:


During an interview on 8/31/18 at 10:00 am, the operating room technician (ORT) stated there was a fire in the OR 2 months ago. The ORT stated it occurred during a dental procedure. The ORT stated the dentist brought in their own headlamp equipment with an extra lithium battery pack. The spare lithium battery pack malfunctioned and caught fire. The ORT stated equipment should be checked by Biomedical prior to bringing it into the OR.


During an interview on 8/31/18 at 11:05 am, the Biomedical Technician (BT) stated the dentist brought in their own headlamp with an extra lithium battery pack. The BT stated the spare lithium battery pack exploded. The BT stated the facility was working on getting rid of lithium batteries in the OR because they "can just go off." The BT further stated to check a battery would be a visual check. The BT stated she did check the head lamp and would provide me a copy of the equipment inspection form for the headlamp.


Review of the "Biomedical Services Department Equipment Inspection Form" revealed an inspection for "Light Source" was completed "6/18". There was not a specific date on the form, only the month and year.


During an interview on 8/31/18 at 3:45 pm, the Director of Quality Management (DQM) confirmed the battery caught fire in the OR on 6/22/18. The DQM stated the anesthesia was reversed for the patient, and the patient was then brought to the recovery room.


During a phone interview on 9/7/18 at 3:00 pm, the Chief Nursing Officer (CNO) stated this was the first time the facility had encountered a faulty lithium battery that exploded. The CNO stated that all lithium batteries were banned. The CNO further stated the OR staff were unaware that the dentist brought a lithium battery into the OR. She stated it was a spare battery used for the dentist's headlamp, which caught fire. The CNO stated the OR staff did not know that the headlamp or spare battery belonged to the dentist and not the facility.


Review on 8/31/18 of the facility's "SAFETY PLAN" revealed "All grounds and equipment will be maintained in a safe manner. The maintenance and supervision of grounds, equipment...is accomplished through monitoring and preventive maintenance programs, which are performed by the Engineering staff and contract services."


Review on 9/7/18 of the facility's policy "EQUIPMENT MANAGEMENT PROGRAM" with an effective date of 4/23/18, revealed "South Peninsula Hospital will have a preventive maintenance program designed to ensure the proper functioning, safety and performance of all electrical and mechanical equipment used in the care, diagnosis, and treatment of its patients or residents ...The equipment inventory will be maintained as long as the equipment is in active use within the facility. Equipment maintenance records will be maintained in specific files for each unit or device for the life of the equipment."
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