Case Study
Fire in the OR
Description
A 74-year-old male undergoing a temporal artery biopsy suffered second-degree burns on his face when oxygen came into contact with the electrocautery device being used for the procedure.
Key Lessons
- The risk of an operating room (OR) fire should be assessed in the holding area, as well as early in the time out checklist
- Implement standardized annual OR fire education for all team members
Clinical Sequence
A 74-year-old male with a history of right-sided neck pain and temporal headaches was admitted to the hospital for a temporal artery biopsy to rule out temporal arteritis. In the OR, the circulating nurse put the electrocautery device on a standard setting. The anesthesiologist placed a face mask on the patient, covering his nose and mouth, to deliver oxygen (a strap could not be used as the area needed to be accessed for the biopsy).
The vascular surgeon applied a local anesthetic and then, assisted by an intern, draped the patient’s face and prepped him with a chlorhexidine gluconate solution. Due to the drapes, the anesthesiologist was unable to fully visualize the vascular surgeon or the patient’s face.
The patient’s skin was incised with a scalpel, then the dissection of subcutaneous tissue with electrocautery started. The surgeon observed a yellow spark from the tissue, along with the smell of smoke, and the patient began thrashing around. The scrub nurse pulled back the drapes and observed flames in the mask. The mask was removed, the oxygen was turned off, and the fire was put out by dousing it with saline. A fire alarm was pulled per protocol.
An ENT consult was obtained. The patient had singed nose hair and a burned lip. His wounds were cleansed, and he was given pain medication. The patient was intubated and transferred to another hospital’s burn unit for further treatment of neck and facial edema.
Subsequently, the patient was discharged home with services for wound care.
Allegation
The patient sued the vascular surgeon for negligence while using a cautery device that resulted in his burns.
Disposition
This case was settled in the high range (>$500,000).
Analysis
- The risk of OR fires, which can have devastating consequences, is underappreciated.
Any procedure that uses cautery should be considered a high risk for fire, particularly if it is used above the xyphoid process. In this case, the procedure involved the three components of the fire triad: the use of cautery on the head (an ignition source), a loose oxygen mask on the face (an oxidizer), and the use of a flammable cleansing agent (fuel), which were within inches of one another. The Joint Commission now requires organizations to periodically evaluate potential fire hazards that could be encountered during operative or invasive procedures and to establish written fire prevention and response procedures, including safety precautions related to the use of flammable germicides or antiseptics. An annual standardized OR fire education program of all OR trainees and staff combining didactic and interactive components would provide a strong foundation for preventing fires in the OR. The Association of Operating Room Nurses has produced a Fire Safety Tool Kit for educational purposes.
- The need for a fire risk assessment should begin before the patient enters the OR.
At the time of this event, a fire risk assessment was not done. As a result of this incident, a fire risk assessment is being performed at the time out for all procedures at this organization. Although this is a step in the right direction, the optimal time to do a fire risk assessment is before the patient enters the OR, as this will provide time for the anesthesiologists to adjust their plans accordingly. In addition, the final time out before the procedure begins should also include a fire risk assessment, ideally at the top of the checklist.
- A task force convened by the Academic Medical Center Patient Safety Organization published Patient Safety Guidance for Perioperative Fire Safety, which provides additional guidance in OR fire risk reduction
REFERENCES
Jones TS, et al. Operating Room Fires. Anesthesiology 2019; 130:492–501
Acevedo, E. K. (2021, 3 17). The Economics of Patient Surgical Safety. Surgical The Clinics, pp. 135-148.
Choudhry, A. H. (2016, July). Surgical Fires and Operative Burns: Lessons Learned From a 33-Year Review of Medical Litigation. The American Journal of Surgery, pp. 558-564.
Connor, M. M. (2017, 2 17). Operating room fires in periocular surgery. Int Ophthalmol,pp. 1085-1093.
Cowles, C. C. (2019, May). Prevention of and response to surgical fires. British Journal of Anaesthesia,pp. 260-266.
Cowles, C. L. (2021). Surgical Fire Prevention: A Review.Anesthesia Patient Safety Foundation.
Description
A 64-year-old female registered nurse (RN) alleged that her 29-year-old manager discriminated against her based on her age.
Chronology of Events
A 64-year-old female registered nurse (RN) alleged that her 29-year-old manager purposely hired a young woman for an open position and commented about that new hire’s youthful appearance. The complainant further contended that—after she complained about that comment—her manager assigned her extra work that fell outside of her job description.
These alleged actions occurred while the clinical unit was scaling back RN shifts due to the COVID-19 pandemic. Although changes in job duties were universal, the complainant contended that she was singled out and given duties she did not feel safe performing.
Citing health issues from the alleged discrimination, the complainant took medical leave, and filed an age-discrimination complaint with the Massachusetts Commission Against Discrimination (MCAD)
In response to the complaint, the employer noted that there were several staff around the complainant’s age and that the “young” new hire was the only applicant for the opening. They acknowledged that the manager had, on one occasion, described the new hire as “young,” and was counseled by Human Resources regarding the inappropriateness of this type of comment. In addition, the employer demonstrated that the claimant and a younger employee were both issued performance warnings for comparable conduct.
The employer was also able to demonstrate that the COVID-related modifications were applied to all RNs on the unit, and that the complainant did not meet these revised expectations. Documentation confirmed that the claimant was counseled by her manager several times about meeting her job requirements.
Complaint
The complainant alleged age-based discrimination and unfair job demands.
Disposition
MCAD determined the nurse’s complaint lacked probable cause. Specifically, MCAD concluded that the employer provided nondiscriminatory reasons for modifying the unit nurses’ job duties, and that those extra duties were included in the job description. Finally, MCAD determined that manager’s “young” statement constituted a stray remark insufficient to show any discriminatory motive or intent.
Discussion Points
- Could this complaint have been avoided if the manager had not uttered the “youthful” comment?
- What is the employer’s responsibility when job duties are changed for existing employees?
Learn more about Employment Practices Liability
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