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METROSOUTH MEDICAL CENTER 12935 S GREGORY BLUE ISLAND, IL 60406 Aug. 9, 2017
VIOLATION: OPERATING ROOM POLICIES Tag No: A0951
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) clinical record reviewed, involving fire in the operating room (OR), the Hospital failed to ensure appropriate equipment was used during surgery.

Findings include:

1. On 8/3/17 at approximately 10:40 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a [AGE] year old male admitted on [DATE] with a diagnosis of throat malignancy. The clinical record indicated that Pt. #1 was scheduled for awake tracheotomy (surgical procedure to create airway through the neck) on 7/28/17. During the surgery in the OR, the clinical record indicated that the electrocautery "got fired and facial burn developed" on Pt. #1.

2. On 8/8/17 at approximately 10:00 AM, the Hospital's policy titled "Fire Safety in Invasive Procedural Areas" (revised 6/21/17) was reviewed, and required, "... f. If open oxygen sources are employed, use bipolar electrosurgery... (such as cauterization during head, face, neck, and upper surgery). Bipolar electrosurgery creates little or no sparking... and has not been involved in starting any surgical fires."

3. On 8/3/17 at approximately 2:14 PM and 8/8/17 at approximately 12:00 PM, interview was conducted with E #1 (Director of Surgical Services). During the interview, E #1 stated that MD #1 used unipolar electrocautery on Pt. #1 on 7/28/17. E #1 also stated that bipolar electrocautery was available for use in the operating room.

4. On 8/3/17 and 8/8/17 between 9:35 AM and 3:00 PM, intermittent telephone interviews were conducted with MD #1 (Surgeon). MD #1 stated that the oxygen mask placed on Pt. #1 may not have sealed the face of Pt. #1. MD #1 stated that he would not have used electrocautery if he knew 100% oxygen was used on Pt. #1. MD #1 also stated that unipolar electrocautery was used on Pt #1 during the surgery, and that use of unipolar versus bipolar electrocautery is dependent on the situation and the type of patient's surgery.