Surgical burns remain a key concern for safety advocates

When Massachusetts General Hospital (MGH) recorded six cases of burns to surgical patients from 2013 through 2015 (four of them in 2015), safety leaders set out to reduce that to zero.  

In that three-year period, MGH said it had performed 100,000 operations, but caregivers took the view that one preventable burn was one too many. They determined that most skin burns were caused by improper handling of electrosurgical units (ESUs) and put a multidisciplinary team on the problem. MGH’s most common ESUs are pencil-shaped devices designed to stop bleeding by cauterizing tissue; they are usually referred to by their original trade name, Bovie.

Other causes of patient burns

ECRI Institute has long warned of the many possible causes of burn injuries, and provides prevention resources and toolkits here. Beyond surgical burns, state officials and safety groups keep records on other types of burns when they are classified as second degree or greater:

  • Hot food or beverage spills. These occur most often when items are heated in a facility's microwave for longer than the proper time, and when hot food is not given enough time to cool down before patients or residents start eating.
  • Injuries from overheated or makeshift warming devices, like blankets, hot towels or heat packs. Burns can also occur when heating devices are created from unapproved materials and warmed in microwaves. Burns from ice packs also occur.

In 2016 in Massachusetts, 94 burns were reported to the Department of Public Health as serious incidents (second-degree burns or greater) by long-term-care facilities; most of those causing serious injury were due to hot beverage spills or heating and warming devices.

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Burns Poster 1
Burns Poster 1
Bovie safety poster

The hospital’s improvement efforts included staff education and signage in ORs, as well as burn simulation training. They also created videos showing how to use MGH’s four updated “fire risk safety assessment forms," which are required for all OR procedures. A poster campaign was also developed, adopting a Western theme — “Holster that Bovie."

Statewide, surgical burns affecting patients and staff are a relatively small but persistent and potentially devastating problem for acute-care hospitals and ambulatory surgery centers. According to data from the Department of Public Health, 25 surgical burn cases were reported as serious events from 2013 through 2015 in Massachusetts. (See burn classification chart below, which also lists burns from spilled hot food or beverages and from warming devices.)

Lessons from other Mass. providers

These summaries show how hospitals that experienced surgical burn incidents altered policies and procedures to prevent recurrences.

Bovie burn to surgical patient

What happened: During surgery, a doctor placed his Bovie pencil on an antimicrobial incision drape covering a patient’s thigh. The Bovie singed the drape and burned the patient’s leg. The resident assisting the surgeon was still depressing the foot pedal powering the Bovie when the surgeon placed it on the drape.

Steps taken: The hospital eliminated foot-pedal-controlled Bovies from ORs, and the case and the policy changes were reviewed extensively during surgery mortality and morbidity rounds.

UV lighting injuries to OR staff

What happened: Two staff members working in the OR experienced eye irritation. A third staff member who entered the OR noticed a blue glow from its UV panels indicating that UV lights were on. The UV lights were turned off and the injured staff were treated with eye drops and antibiotic ointment. One was diagnosed with corneal abrasions and told the healing would take place gradually over the next two weeks.

Steps taken: An internal investigation determined that the staffers had not realized the UV lights were on (UV lights were not used in operating rooms on that floor) and that the lights had been inadvertently switched on at an earlier time. The circuit breakers were turned off to all rooms equipped with UV lighting while new safety procedures could be initiated and caregivers could be educated about the precautions.

Separate circuit breakers were installed in UV-equipped ORs that are kept off unless the rooms are booked for UV cases. All UV light switches were enclosed in spring-loaded covers that can only be turned on intentionally. All dials used to set the intensity of UV lights were placed in locked enclosures accessible only to biomedical technicians during safety checks.

Signs were put on the doors of UV-equipped ORs to remind staff members of the new practices. The hospital also consulted peer institutions about OR UV lighting safety and learned that the head coverings used by OR staffers were not adequately protective. Steps were taken to upgrade the surgical caps.

Burns Poster 2
Burns Poster 2
Drape safety poster

Operating room fires also pose risks

MGH has also focused on preventing other OR burn risks, including fires.

“We also do a lot on awareness of fire safety to keep it foremost in people’s minds,” said MGH’s Maureen Hemingway, DNP, RN, CNOR, nursing practice specialist in Perioperative Services, who chairs the Association of periOperative Registered Nurses (AORN) simulation task force. “The possibility of a surgical fire needs to be a focus of all team members.”

Maureen Hemingway

Surgical burns can be curtailed if close attention is paid to basic safety measures. Those steps include conducting fire risk assessments before the start of all procedures and greater awareness of operating room ignition sources (like cautery and laser devices), fuel sources (like surgical drapes and alcohol-based skin preparation agents), and oxygen flow levels.

Burn Classification Chart
Burn Classification Chart
Serious Reportable Events involving burns, 2013-15

Recommendations from expert safety groups like the ECRI Institute also include designing fire mitigation strategies that specify a clear role for each staff person present; and incorporating the fire risk assessment and discussion into the surgical timeout as a standardized practice.

Burn Picture
Burn Picture
Sandra Silvestri

Preparation and prevention are vital

MGH has found success focusing on those very steps, said Jana B. Deen RN, JD, the senior director of Patient Safety in the MGH Lawrence Center for Quality and Safety, and Sandra Silvestri, RN, MS, CNOR, nursing practice specialist in Perioperative Services.

“Before any person is brought into the OR for a surgical procedure,” Silvestri said, “the entire team huddles to discuss the patient.” They talk about the surgical incision, the patient’s medications and antibiotics, and note whether an open oxygen source (like a nasal mask or cannula) is involved. They also check to see whether prepping agents like alcohol or other flammable chemicals will be used. Surgical teams complete the fire risk assessment checklist for each patient and procedure no matter how high or low the risk level.

Hemingway also supports simulation as a tool to improve safety. MGH nurses, anesthesiologists and surgeons simulate scenarios such as drapes catching fire or an entire OR going up in flames. 

“For procedures with a high fire risk, team discussion and prevention are key,” she said.

Jana B. Deen

‘Speaking up’ is equally important

As for proper handling of Bovies, they should be placed in a plastic holster when not in use. As Hemingway noted, “ESUs are safe devices for surgical cautery, but should be used with caution in the presence of ignitable fuels.” Indeed, patients have been burned when ESUs were set down rather than holstered – prompting MGH’s Western-themed poster.

“They can cause little burns on the skin, like a small burn blister,” Deen said.

Deen believes all providers can reduce burn incidents by following an approach of ongoing awareness and vigilance and by teaching proper techniques to prevent burn situations.

“Speaking up about proper technique when you see someone who isn’t returning the Bovie to the holster is important too,” Deen said.


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