TOP CONCERN The combination of energies and oxygen make head and neck surgery a major fire risk. (Left to right) Karon Kennamer, CST; Stacy Taylor, ST; Cristy Vanzant, LPN, ST; and Kelly Garner, RN, conduct a laser safety drill at Tullahoma Surgery Center.

Protecting patients from flash fires, thermal contact hazards, electrical current, scalding fluids and dangerous chemical or radiation exposures is an absolute must. But it only takes a moment for a seemingly minor misstep to escalate into avoidable and potentially devastating errors. Here are some common causes of unintentional patient burns and practical advice on how to prevent them.

OR fires
Perhaps the worst-case scenario for patient burns, surgical fires are relatively rare but very hazardous. According to the ECRI Institute, the Plymouth Meeting, Pa., non-profit healthcare research organization, they occur approximately 550 to 650 times a year in the United States, resulting in about 20 to 30 patient injuries.

The risk of OR fires is particularly acute due to the fact that the necessary elements of the "fire triangle" — a heat or ignition source, an oxidizer and fuel — are often present and abundant in the close confines of the surgical suite. Minimizing the risk means strictly controlling each component of this potentially dangerous combination.

• Heat or ignition source. The energies generated by electrosurgery and electrocautery units are put to use in nearly every case. Minimally invasive procedures demand bright endoscopic and arthroscopic light sources. Some specialties employ power tools or lasers to achieve their aims. There's no shortage of electrical equipment in the OR that can produce heat or spark, and consequently increase the potential risks of OR fires and patient burns.

Never set hot instruments on surgical drapes or other flammable materials, even for just a few seconds. Place electrosurgical handpieces in their holsters when not in use, and ensure other heat-generating devices are either safely off the field and switched off, or with their ends covered by a guard or damp cloth. Activate electrical devices only when their cables are connected and they're ready to use, and avoid excessively prolonged use. With regard to electrosurgical instruments, only the surgeon should control the hand- or foot-switch, and only when the active tip is directly in his view.

• Oxidizer. The surgical atmosphere is oxidizer-rich. The flow of high-quality oxygen, nitrous oxide, compressed medical air and efficiently ventilated ambient air all present risks. Surgical sites on the head, neck and upper chest are especially perilous, given the use of electrosurgery in close proximity to the delivery of oxygen. Fire safety experts at ECRI recommend reducing this risk by administering ambient air instead of 100% oxygen for open delivery, if sedated patients' oxygen saturation levels remain stable without extra oxygen, or by securing the airway with an endotracheal tube or laryngeal mask airway to prevent the escape and accumulation of oxygen.

• Fuel. Virtually every material at the surgical site can catch fire. Drapes, gowns and caps; linens, towels and sponges; gauze, dressings and tape; skin preps, degreasers and tinctures; anesthesia masks, cannulas and tubing; or a patient's tissue, hair and intestinal gas. The key is to reduce the risks that fuel sources present and exercise extreme caution. Make sure skin prep solutions are completely dry before surgery begins, or avoid flammable alcohol-based preps entirely. Tape a patient's hair or slick it back with a water-based lubricant. And, as mentioned, never place heat-generating devices on drapes or the patient.

FRONTLINE FOCUS Every member of your surgical team must be aware of burn risks, including not-so-obvious dangers.

STAFF EDUCATION

Plan Your Prevention

The Centers for Medicare and Medicaid Services and the leading accreditation agencies, not to mention local, state and federal authorities, require surgical facilities to implement fire safety policies. But protecting your patients against burn injuries involves a wider focus than quarterly surgical fire drills.

Your thorough risk assessment and prevention policy should include the likelihood of burn injuries resulting from the thermal extreme of flash-sterilized instruments, a chemical reaction from prep solution pooled on the skin or the improper use of electrical nerve stimulators. Add a notification of potential burn injury risks to pre-op time outs.

Training builds awareness of the risks that staff might not have seen. AORN, the ECRI Institute, the Anes-thesia Patient Safety Foundation and other sources offer a wealth of useful educational materials and recommendations. Use them to inform your frontline staff during regularly scheduled in-services.

— Marilyn Burns, RN, BS, CNOR

Patient warming
Anything that can cause a fire can harm a patient, but an OR blaze isn't the only perioperative pitfall that can leave patients burned. In fact, the fire triangle isn't even necessary for injuries to occur. Non-fire related burns are an often-overlooked issue in patient safety and burn prevention efforts, but their consequences can be just as severe as those of a flash fire. The improper use of patient warming devices, and of convective (forced-air) warming systems in particular, is a main offender on this front.

The design of a convective warming system incorporates a forced-air unit connected by hose to a single-use patient blanket or gown, which diffuses the hot air. Safety authorities have reported incidents in which facilities neglected to purchase or use the disposable components and instead placed the hose directly under a cloth blanket. This practice, called "free hosing," puts patients at risk of severe burns, especially if they're anesthetized, asleep or immobile as the forced hot air blows unceasingly at their skin.

Safe patient warming depends on the proper use of warming systems. Always consult and train your staff to observe the manufacturers' directions. Assemble the devices correctly, and discourage free hosing when convective systems are used. Set the warmers to appropriate temperatures that are acceptable to patients, and return for occasional checks on them. When it comes to patient warming, don't just set it and forget it.

It's possible that thermal burn injuries are underreported or initially unobserved, like medical error near-misses. But now that patient burns are reported as a data quality measure, perhaps we'll see more awareness raised of patient warming's potential danger.

HEAT IS ON Light sources and other electrical equipment can generate enough heat to burn through drapes. Mike Shelton, RN, demonstrates for clinical manager Kristen Barnes, RN (left), and Jennifer Barbeau, RN, at Tullahoma Surgery Center.

Stray energies
In addition to their potential role as heat and ignition sources in OR fires, electrosurgical instruments may also pose a risk for burn injuries through stray electrical current. If such injuries occur during laparoscopic use and out of the surgeon's direct line of sight, they may not even be noticed until the patient suffers post-op (and post-discharge) complications as a result.

Careful handling and use of electrosurgical equipment can prevent burns from direct but unintended contact between active electrodes and tissue, or from accidental device activation. Burns resulting from direct or capacitive coupling require another level of caution, and a full understanding of how electrosurgery works. That's why routine inspection, testing, maintenance and staff training are essential to electrosurgery safety.

• Direct coupling is the result of an active monopolar electrode touching an uninsulated metal object, which conducts the current to adjacent tissue. Most physicians who employ electrosurgery know to avoid touching devices' tips to other metal instruments or implants, but even metals outside of the immediate operative site, such as the surgical table, positioners, stands, poles and gown snaps, can also conduct current and should be adequately covered.

• Capacitive coupling can unintentionally burn tissue or skin when electrical current passes between conductors (even insulated ones) that are close to each other. This is sometimes the result of current leaking through damaged insulation, which underscores the importance of routinely inspecting the condition of electrosurgical units' insulation. Even breaches that aren't visible to the naked eye can be hazardous, so consider the use of an insulation scanner while setting up cases. An active electrode-monitoring device can also alert you to insulation breakdown while performing its preventive task of overseeing the electrosurgical current — and shutting it down if it detects stray energy, to minimize potential injuries.

Never again
Patient burns in the perioperative setting are 100% preventable, but awareness, education and action are required to ensure patients remain safe in your care. By communicating the risks to staff, reporting incidents and utilizing available guidance, you'll ensure these never events never occur on your watch.