Allegation
Negligent preparation of surgical site and oxygen administration during surgery alleged in patient injury
Case Details
A 60 YOM presented to the emergency department with c/o garbled speech. Past medical history included HTN and DM2. Stroke imaging revealed no evidence of an acute bleed or MI. Neurology was consulted and on evaluation patient was positive for temporal artery tenderness concerning for giant cell neuritis. A temporal artery biopsy was recommended. The patient left against medical advice but his wife convinced him to return the next day and he was admitted to the hospital for an emergency biopsy. Anesthesia’s preop assessment noted the patient as a Mallampati score of 3 with an ASA score of 4E. After discussion with the neurosurgeon, it was decided that MAC sedation with general anesthesia backup would be used.
The patient’s surgical site was prepped with chlorhexidine and draped by the OR staff. Anesthesia began administration of 4L of oxygen mixed with 2L of medical air. Fentanyl and propofol were given IV achieving an appropriate level of sedation to begin the biopsy. VS were stable and O2 saturation was 97%. Anesthesia categorized and documented the fire risk as a level 3 or high risk (1 point surgical incision above the xiphoid process; 1 point open oxygen source via facemask or nasal cannula; 1 point ignition source in use). Within seconds of the first surgical incision the anesthesiologist saw sparks and flames spilling out from the surgical drape. The neurosurgeon stopped the procedure immediately and the oxygen was turned off. Anesthesia attempted to douse the flames with sterile water, but the drape continued to burn. The surgeon threw it to the floor where it was put out with a fire extinguisher. Anesthesia successfully intubated the patient in a single attempt to secure the patient’s airway. The patient suffered second and third degree burns to his face, lips, tongue, neck, and chest. He was transported by air to a nearby burn unit. The patient underwent three skin grafts and claims he has blurred vision in his left eye and diminished hearing in both ears since the event.
Expert Testimony
Expert reviews were mixed regarding standard of care between surgery and anesthesia. The anesthesia expert opined that the level of O2 was too high and that the ratio to medical air was inappropriate. He also expressed concern that OR staff may have failed to allow complete evaporation of anesthetic materials and antiseptic vapors contributing to the fire. There was expert support for the surgeon, but the defense was concerned that a jury would be overly sympathetic to the patient once photos were shown, that could lead to an excess verdict.
Resolution
The case was settled prior to trial as defense attorneys identified inaccuracies and conflicting documentation in the medical record that they felt diminished the credibility of both physicians.
Risk Reduction Strategies
Surgical fires are life-threatening events. The fire triad only requires three factors to be present for combustion to occur: an oxidizer, fuel, and an ignition source. Understanding this and that every staff member has a responsibility to ensure proper steps are taken to protect patients is essential to prevent fire events and avoid patient harm. Consider the following strategies to assist with management of anesthesia and oxygen for patients undergoing surgical procedures to reduce your liability risk:
- Implement a surgical safety checklist to identify procedures with an increased risk for spontaneous surgical fires.
- Utilize effective fire prevention strategies with a focus on review of supplemental oxygen, types of antiseptics used in procedure rooms and other flammable liquids or medical supplies in or around the procedure area.
- Consider wetting surgical drapes or using flame retardant drapes to minimize surgical fires and to manage fuel sources.
- Document details of each patient encounter clearly, factually, and timely to support your care and treatment decisions.
- Add simulation training of surgical fires to annual competencies for all healthcare professionals that work in procedural areas that utilize anesthesia and oxygen.
Resources
The World Health Organization Surgical Safety Checklist
Risks and Prevention of Surgical Fires
Authors
Michele Crum, MSM, MSN, RN, CPHRM, FASHRM |
Gerryann Whalen, BS, RN, CPHRM, ONC |