The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|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.
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.