In response to a rash of patient burns in the operating room over a two-year period, patient safety leaders at Massachusetts General Hospital launched an initiative to eliminate that problem.
Six patients were burned during surgery at Mass General between 2013 and 2015, with four cases in 2015, according to a post from the Betsy Lehman Center for Patient Safety, a state agency that aims to improve healthcare safety in Massachusetts. Staff determined that the burn cases were preventable, as most were caused by inappropriate handling of electrosurgical units.
The hospital posted warning signs in ORs and offered additional staff training that included burn simulations. Staffers were also urged to use updated forms to assess fire risk and safety measures.
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“We also do a lot on awareness of fire safety to keep it foremost in people’s minds,” said Maureen Hemingway, R.N., a clinical nurse specialist at the hospital. “The possibility of a surgical fire needs to be a focus of all team members.”
Basic safety protocols can effectively curb surgical burns, according to the post. Surgeons and their teams must be aware of ignition sources such as laser or cautery devices, fuel sources such as drapes, and oxygen levels to prevent burns or fires.
Team members also need to be encouraged to speak up if they see anything worrying, particularly with the electrosurgical units. For instance, in one case listed in the article, a patient was burned because the surgeon set one of the units on the patient’s leg while a team member still had their foot on the operating pedal, scorching their antibiotic dressing and skin.
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Safety checklists and other preoperation procedures can significantly reduce risks if put into place correct, as FierceHealthcare has reported. Recent research has shown that using checklists before surgery can reduce patient mortality rates, but deployment can be uneven.
To succeed, these safety measures require buy-in from leadership and staff who will be using it, and checklists and other protocols may require adjustment as they’re rolled out more widely. But a culture of safety in the OR can lead to improved patient outcomes.