Operating Room Flash Fire Leads to Severe Burns in a 2-Month-Old Patient

Case Overview

This pediatric burns case involves a 2-month-old girl who required surgical repair for a heart condition. During the procedure, there was a flash fire in the operating room (OR which manifested from alcohol vapors used to prepare the patient for sterility. The child suffered severe burns and burn-related injuries and required ICU care for an extended time period.

Questions to the Hospital Administration expert and their responses

With regards to patient safety, is it beneath the standard of care to fail to follow proper protocol to eliminate alcohol vapors which can result in surgical fires?

The joint commission has specific safety standards concerning staff training and practice in relation to surgical fires. Proper communication could and should have stressed OR safety to the physician. Nurses and nursing managers have a duty to serve as an advocate for the patient and create a safe patient environment. The care provided by the nursing and hospital staff in general most likely fell below the standard of care. This particular case may be in violation of those standards.

About the expert

This Fellow in the American College of Healthcare Executives is qualified to comment on standards of patient care in the clinical setting. He is currently responsible for the quality of care delivered at a major Texas hospital. He served in an administrative capacity of a 628-bed hospital center and was previously interim CEO of small, urban hospital. Prior to his current position, he was the administrator directly responsible for the hospital's laboratory and toxicology lab.