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Publication Type: Patient Safety Advisory
Single or Multiple Incident: Multiple
Date: 3/1/2018 12:00:00 AM

This alert discusses the patient safety incidents of burns associated with events occurring in healthcare environments that do not include surgical areas. An analysis of reports submitted in 2016 through PA-PSRS identified 230 events of burns, of which 61.3% occurred in nonsurgical healthcare settings. Of the 141 nonsurgical burns 75.9% were considered thermal in nature (caused by direct contact with heat sources such as hot metals, scalding liquids, steam, and flame). The most frequent thermal burns involved dietary spills of heated drinks or food (49.5%) and heating devices (30.8%), including powered devices such as circulating water or air blankets, warm compresses, and instant hot packs. The majority of burn events reported occurred in areas outside of the operating room, including critical care, obstetrical, postanesthesia, rehabilitation, behavioral health, medical/surgical specialty, and outpatient units. The alert classifies and defines the type of burn injuries experienced; burns can be thermal electrical, radiation related and/or chemical. 75% of burns reported were thermal in nature. Of the thermal burns, the majority involved dietary spills of heated drinks or food (49.5%) and heating devices (30.8%), including powered devices such as circulating water or air blankets and nonpowered devices such as heated compresses, packs, or water bags. More than one-third of the burn injuries reported involved the use of medical devices, including pulse oximeters, electrical nerve stimulators, defibrillators, ultraviolet light (phototherapy) equipment, and MRI scanners. The alert describes a number of patient factors that can increase the risk and severity of burn injury. Implementing processes to assess and identify patients at risk for burns and developing risk reduction strategies, as identified in the alert, are key to decreasing nonsurgical, healthcare-associated burns. Highlighting the relationship of temperature and time to development of a serious burn is essential in burn risk education; an object that feels only warm to the touch can cause serious injury if left on the skin over time.

Additional Details

Device:
hot compresses, hydrocollator, moist heating pad, magetic resonance imaging (MRI), circulating water devices, air blankets, warm compresses, instant hot packs, electrosurgical devices, pulse oximeters, electrical nerve stimulators, defibrillators, ultraviolet light (phototherapy) equipment, MRI scanners, warming cabinets, instant hot water dispensers, microwave ovens, defibrillation paddles, electroencephalogram (EEG) electrode, sweat test electrode, iontophoresis machine, left ventricular assist device (LVAD)
Medication/Gas/Fluid:
general anesthesia, sedatives, neuromuscular blockers,
Medication/IV List:
anesthetic agents, general, inhaled and IV, neuromuscular blocking agents (e.g., succinylcholine, rocuronium, vecuronium)


Hot Topic: Nonsurgical, Healthcare-Associated Burn Injuries