Fire In Hospital OR Injures Patient

By Walter F. Roche Jr.

A 60-year old patient suffered facial burns and had to be transferred to a tertiary care burn center after a fire broke out in an operating room in a Pocono Mountain health facility.
In a six-page report recently made public by the state Health Department the fire was attributed to the fact that one of the staffers assigned to the operating rooom had not been trained on proper procedures to avoid a fire when skin preparations with alcohol, oxygen and cauterizing equipment are in use.
Saint Luke's Monroe Campus Hospital had been given a waiver to allow for oxygen use in cauterizations but the conditions of that waiver were not met, the report states.
"It was determined that the facility failed to ensure staff working in the operating room were educated in the use of surgical skin preparations that contain combustible agents," the April 21 report states.
In fact a second person in the operating room on April 15 also was untrained but apparently was not directly involved in the incident.
The report notes that the patient was oxygen dependent and required a face mask placing him in the highest risk category for fire.
The state investigation determined that it was the cauterizing equipment that caused the fire which spread to a drape.
"The drape was taken off the patient's face and the fire was extinguished, the report continues.
The patient was then intubated to assess any airway damage, but no injury was found. Injury, however, was detected to the nose and eyelids and further testing was needed to determine any ocular injury..
The recommendation called for transfer to a tertiary care burn center. The report does notindicate the patient's ultimate outcome
A review of hospital records showed no evidence that two staffers, including the one imvolved in the fire. had been trained in the use of surgical skin preparations thar include combustible agents.
In its plan of correction, which was accepted by state health officials said staff would be re-educated on the requirements and safety procedures to be followed in the event of fire in an operating room.
Hospital officials did not respond to a series of questions including the status of the injured patient.
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