@article{ref1,
title="Flash burns while on home oxygen therapy: tracking trends and identifying areas for improvement",
journal="American journal of medical quality",
year="2016",
author="Wolff, Kristina B. and Soncrant, Christina and Mills, Peter D. and Hemphill, Robin R.",
volume="32",
number="4",
pages="445-452",
abstract="The objective was to analyze reported flash burns experienced by patients on home oxygen therapy (HOT) in the Veterans Health Administration (VHA) using a qualitative, retrospective review of VHA root cause analysis reports between January 2009 and November 2015. Of 123 cases of reported adverse events related to flash burns, 100 cases (81%) resulted in injury, and 23 (19%) resulted in death. Although 89% of veterans claimed to have quit smoking (n = 109), 92% (n = 113) of burns occurred as a result of smoking. The most common root cause was risk identification issues. Recommended actions were standardized risk assessment policies, patient education, and the adoption of fire stop valves. Patients with a history of smoking who are on HOT should be considered for fire stop valves and offered consistent counseling and follow-up using a combination of harm reduction and shared decision-making techniques. Standardization of risk identification and documentation is recommended.<br><br>© The Author(s) 2016.<p /> <p>Language: en</p>",
language="en",
issn="1062-8606",
doi="10.1177/1062860616658343",
url="http://dx.doi.org/10.1177/1062860616658343"
}