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Oxygen Mask Ignited By Electrocautery Spark
ISSUE: What is the duty of a healthcare provider to protect patients from hazardous physical conditions?
A 78-year-old woman with longstanding diabetes and coronary artery disease was hospitalized for a right carotid endarterectomy to be done under moderate sedation. She received supplemental oxygen through a rubber oxygen mask that came in only one size and did not provide an airtight seal.
During the procedure, the surgeon used an electrocautery unit provided by the hospital. The surgical drapes obscured the surgeon's view of the patient's face and the oxygen mask. The anesthesiologist was the only person who could see the patient's face. During the procedure, a "popping" sound appeared to be coming from the electrocautery unit. The circulating nurse checked the settings on the unit and everything appeared fine. After a second "popping" sound, the patient began squirming under the drapes, becoming very agitated. At that point, the physicians realized that the oxygen mask was on fire. The patient's face and chest were burned as a result of the fire. The patient sued, claiming that the fire would not have occurred in the ordinary course of events if those who used the devices had exercised proper care.
A 78-year-old woman with longstanding diabetes and coronary artery disease was hospitalized for a right carotid endarterectomy to be done under moderate sedation. She received supplemental oxygen through a rubber oxygen mask that came in only one size and did not provide an airtight seal.
During the procedure, the surgeon used an electrocautery unit provided by the hospital. The surgical drapes obscured the surgeon's view of the patient's face and the oxygen mask. The anesthesiologist was the only person who could see the patient's face. During the procedure, a "popping" sound appeared to be coming from the electrocautery unit. The circulating nurse checked the settings on the unit and everything appeared fine. After a second "popping" sound, the patient began squirming under the drapes, becoming very agitated. At that point, the physicians realized that the oxygen mask was on fire. The patient's face and chest were burned as a result of the fire. The patient sued, claiming that the fire would not have occurred in the ordinary course of events if those who used the devices had exercised proper care.
From your analysis of the case, assess whether the following statesments are true or false:
| * | The duty of a healthcare provider to be vigilant for hazardous devices only applies when a patient cannot protect him/herself. | True or False |
| * | The danger of having flammable material, an oxygen source and an igniting spark is an evident hazard. | True or False |
| * | A physician using electrocautery can assume that other medical staff has removed all fire hazards prior to use. | True or False |
Expand to check answers
GENERAL PRINCIPLE: A healthcare provider has a duty to protect patients from injury, especially when the patient is unable to protect him/herself.
APPLIED PRINCIPLE: The physicians used an electrocautery unit near an oxygen source, creating an increased risk of fire. The risk of fire was especially great because the type of oxygen mask used did not produce an airtight seal, allowing oxygen to escape near the cautery site. Because of the placement of the drapes, the surgeon was unable to see the proximity of the electrocautery to the oxygen source. In addition, the patient was elderly, ill and sedated, and unable to protect herself. In the presence of flammable material, an enriched oxygen atmosphere and a source of a spark or other igniter, a fire was foreseeable.
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APPLIED PRINCIPLE: The physicians used an electrocautery unit near an oxygen source, creating an increased risk of fire. The risk of fire was especially great because the type of oxygen mask used did not produce an airtight seal, allowing oxygen to escape near the cautery site. Because of the placement of the drapes, the surgeon was unable to see the proximity of the electrocautery to the oxygen source. In addition, the patient was elderly, ill and sedated, and unable to protect herself. In the presence of flammable material, an enriched oxygen atmosphere and a source of a spark or other igniter, a fire was foreseeable.
| * | The duty of a healthcare provider to be vigilant for hazardous devices only applies when a patient cannot protect him/herself. | False |
| * | The danger of having flammable material, an oxygen source and an igniting spark is an evident hazard. | True |
| * | A physician using electrocautery can assume that other medical staff has removed all fire hazards prior to use. | False |