TY - JOUR PY - 2019// TI - Surgical fires and burns: a 5-year analysis of medico-legal cases JO - Journal of burn care and research A1 - Calder, Lisa A. A1 - Héroux, Diane L. A1 - Bernard, Catherine A. A1 - Liu, Richard A1 - Neilson, Heather K. A1 - Gilchrist, Andrew D. A1 - Fish, Joel S. SP - ePub EP - ePub VL - ePub IS - ePub N2 - Surgical fires and unintended intraoperative burns cause serious patient harm, yet surveillance data are lacking in Canada. Medico-legal data provide unique descriptions of these events which can inform burn prevention strategies. We extracted 5 years of data on closed (2012-2016) medico-legal cases involving surgical fires and burns from the database of our organization which, in 2016, provided medico-legal support to >93,000 Canadian physicians. We performed a retrospective descriptive analysis of contributing factors using an in-house coding system and case reviews. We identified 53 eligible burn cases: 26 from thermal sources (49.1%), 16 from fires (30.2%), 5 from chemical sources (9.4%), and 6 from undetermined sources (11.3%). Common burn sources were electrosurgical equipment, lasers, lighting, and improper temperatures (causing thermal burns), cautery or lasers combined with supplemental oxygen and/or a flammable fuel source (causing fire), and improperly applied solutions including antiseptics (causing chemical burns). Nontechnical factors also contributed to patient outcomes, such as nonadherence to protocols (15 cases, 28.3%), failures in surgical team communication (3 cases, 5.7%), and lost situational awareness leading to delays in recognizing and treating burns (7 cases, 13.2%). This retrospective study highlights a need for improved surgical safety interventions to address surgical fires and burns. These interventions could include: effectively implemented surgical safety protocols, surgical team communication strategies, and raising awareness about preventing, diagnosing, and managing surgical burns.

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Language: en

LA - en SN - 1559-047X UR - http://dx.doi.org/10.1093/jbcr/irz108 ID - ref1 ER -