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CAMBRIDGE HEALTH ALLIANCE 1493 CAMBRIDGE STREET CAMBRIDGE, MA 02138 Sept. 14, 2011
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on documentation review, it was determined the Hospital had not implemented its Corrective Action Plan related to its Investigation of an Operating Room fire involving Patient #1.

Findings included:

1) The Hospital reported that on 8/16/11, Patient #1 had a temporal artery biopsy (removal of a small section of the artery in front of the ear) and when the Surgeon utilized electrocautery (an instrument that is heated by electric current to destroy tissue/control bleeding), a flash fire occurred. Patient #1 suffered 1st degree burns on the face and neck and was transferred to a Burn Unit at Hospital #2.

2) A review of the Corrective Action Plan related to Patient #1's surgical fire/burns indicated it called for a fire risk discussion (and if indicated, a fire risk reduction plan) to be added to the preoperative ' Time Out' process/ Check List and for physician/staff (re-)education regarding prevention of OR fires during head and neck surgery.

3.) As of 9/14/11, the Hospital had not implemented the fire risk discussion, added the fire risk discussion step to the ' Time Out' Check List form and conducted the physician/staff re-education regarding prevention of OR fires during head and neck surgery.