Crisis in the operating room: fires, explosions and electrical accidents

Nishiyama, Katsura; Komori, Makiko; Kodaka, Mitsuharu; Tomizawa, Yasuko

doi:10.1007/s10047-010-0513-0

Cited by 10 publications

(16 citation statements)

References 26 publications

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“…20 The most common types of power failure events identified in this study are those where backup generators did not restore power as expected, or power returned, but took additional time for computers and monitors to "reboot." The findings of this study mirror Nishiyama et al 21 and others 2,13 who found that the 3 most common types of power failure are main electrical failure and generator shutdown, generator power surge, and failure of the backup generator or the uninterrupted power supply.…”

Section: Discussionsupporting

confidence: 87%

Power Failures During Surgery: A 2000–2019 Review of Reported Events in the Veterans Health Administration

Soncrant

Mills²,

Zubkoff³

et al. 2021

J Patient Saf

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Objectives:The frequency and impact of power failure on surgical care over time in a large integrated healthcare system such as the Veterans Health Administration (VHA) is unknown. Reducing the likelihood of harm related to these rare but potential catastrophic events is imperative to ensuring patient safety and high-quality surgical care. This study provides analysis and description of reported power failures during surgery (January 2000-March 2019), in the VHA and their impact.Methods: This quality improvement study describes patient safety adverse events related to power failure in the operating room reported by 63 VHA medical centers from the approximately 137 VHAs with a surgical program. Power failure events during surgery reported to the VHA National Center for Patient Safety are analyzed. Results:The authors identify 20 root cause analyses and 135 safety reports. Most events 36.1% (n = 56) resulted from generator delay, equipment reboot delay 21.9% (n = 34), and equipment backup power failure 13.5% (n = 21). Root causes include issues with backup batteries or equipment, engineering and clinical staff communication, standardized procedures for testing power, backup power delay, electrical circuit issues, documentation, and training. Patient harm occurred in 18% (n = 28) and 3.9% (n = 6) as major or catastrophic. Conclusions:Power failure during surgery is associated with major or catastrophic patient harm, though rare. Staff preoccupation with failure, disaster preparedness, and focus on communication has the potential to minimize or avoid patient harm.

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Section: Discussionsupporting

confidence: 87%

Power Failures During Surgery: A 2000–2019 Review of Reported Events in the Veterans Health Administration

Soncrant

Mills²,

Zubkoff³

et al. 2021

J Patient Saf

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“…If the heart is contracting when the pump stops, only the occlusion of the venous line may restore systemic perfusion, sometimes with the help of inotropic support. If the aorta is clamped, the only solution is hand-cranking [ 1 , 2 , 4 , 5 ]. Hand-cranking is effective in terms of restoring systemic perfusion, but the universally accepted time limit for a single person is 15 minutes, to prevent exhaustion [ 1 , 4 ].…”

Section: Discussionmentioning

confidence: 99%

“…During 2000 routine CPB cases in our institution within the period of 4 years, 1 case of electrical failure was observed. Different mechanisms of electrical failure have been reported, including mains failure, generator failure, and uninterrupted power supply (UPS) failure [ 1 , 2 ]. Since these kinds of equipment failure and accidents are very rare, little attention is given to preventative measures concerning electrical supply and backup batteries.…”

Section: Introductionmentioning

confidence: 99%

Electrical failure during cardiopulmonary bypass: a critical moment

Durukan¹,

Gürbüz²,

Ozcelik³

et al. 2016

kitp

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Electrical failure during cardiopulmonary bypass is a crisis situation for the cardiac surgical team. Fortunately, it has a low incidence with low morbidity and mortality rates. Notwithstanding, institutional preventative and management measures should be taken. Here, we report a case of electrical failure during cardiopulmonary bypass, which was successfully managed during the surgery, allowing the patient to recover uneventfully. These unwanted complications can only be managed by promoting awareness and putting in place strategies against them.

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“…In the third subcategory, the patient is definitely involved by the error event with no possibilities of involvement of the surrounding personnel and structures by the same event. Other authors have separately discussed these events, but without sufficient classifications [4,11]. …”

Section: Discussionmentioning

confidence: 99%

“…The term “surgical fires” mainly refers to fires ignited within the operative room in the presence of the surgical fire triangle: ignition source, fuel, and oxygen. However, it could be a broader subject that has different varieties of thermal and electrical injuries in the operative theater including accidents of fires, explosions, burns, and electrocutions [4]. The risks are not only directed towards the patients, but they may also extend to the medical staff and co-workers.…”

Section: Introductionmentioning

confidence: 99%

Experience of a Tertiary-Level Urology Center in the Clinical Urological Events of Rare and Very Rare Incidence. I. Surgical Never Events: 3. Urological Electrosurgical Never Events

Gadelkareem¹

2018

Current Urology

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Introduction: Surgical fires are unique topics that belong to surgical never events and deserve urological attention. Materials and Methods: A retrospective search of our hospital records was done for the states of electrosurgical never events in the period from July 2001 to June 2016. The included events were classified according to the site of occurrence in relation to the patient's body and possibilities of human involvement. The events were studied for the type, extent, damages, personnel involvements, complications, and management. Results: Of more than 82,000 urological interventions, 18 cases (0.022%) of electrosurgical never events were detected. Four subcategories were differentiated: electrosurgical theater fires (33.3%), electrosurgical contact skin burns (38.9%), electrosurgical internal injuries (16.7%), and electrocutions (11.1%). Electrosurgical theater fires included 3 ignition fires with fire skin burns and 3 device explosions. Fires only occurred with the use of alcoholic skin disinfectants. Contact skin burns resulted from inadvertent direct electrosurgical contacts, with 2 burns on the back, 3 burns on the lower limbs, 1 burn at the penile shaft, and 1 burn at the suprapubic region. Only 1 case of contact skin burn required plastic surgery. Electrosurgical internal in-juries involved the intestine, spleen, and urethra and were followed by major complications. Electrocutions involved a doctor and a patient with multiple bone fractures in the former. Conclusion: Urological electrosurgical never events are very rare incidents and were differentiated into 4 clinical subcategories. Human involvements varied from absence to major devastating complications. Reduction of these events depends on the adjusted use of electricity-based armamentarium.

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Crisis in the operating room: fires, explosions and electrical accidents

Cited by 10 publications

References 26 publications

Power Failures During Surgery: A 2000–2019 Review of Reported Events in the Veterans Health Administration

Power Failures During Surgery: A 2000–2019 Review of Reported Events in the Veterans Health Administration

Electrical failure during cardiopulmonary bypass: a critical moment

Experience of a Tertiary-Level Urology Center in the Clinical Urological Events of Rare and Very Rare Incidence. I. Surgical Never Events: 3. Urological Electrosurgical Never Events

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