Protocol error leads to patient burning during pacemaker surgery

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A patient undergoing heart pacemaker surgery was burned on her face, lips and shoulder when a fire burst out from under the sterile drapes covering her body at Abbott Northwestern Hospital in Minneapolis.

Doctors and nurses immediately doused the fire and completed the surgery, according to a state investigative report made public Monday, and reported in the Star Tribune.

The Tribune reported that state health investigators found that the hospital violated safety and procedural policies that contributed to the June 24 incident. The unidentified patient, who was lightly sedated, woke up when the fire ignited and "was very frightened," according to the report. She suffered first- and second-degree burns, and was kept in the hospital for two days after the accident.

The fire most likely occurred because the surgeon was using a cauterizing tool near the patient's nose tube -- a violation of safety protocols -- and because oxygen had pooled beneath improperly draped sterile sheets, Darcy Miner, director of compliance monitoring for the Minnesota Department of Health told the Tribune.

Abbott reported the incident to the state health department, prompting the investigation by both health officials and the state fire marshal's office. The report said that doctors and hospital staff involved in the incident have been ‘re-educated’ on safety protocols.

The surgeon was in the process of cauterizing the area inside the patient's body that would hold the pacemaker when the left side of the sterile drape and the nasal prongs on the oxygen tube to her nose suddenly caught fire, according to the Tribune. Both were quickly removed, and the fire extinguished, but she was burned on her nose, shoulder and face. The pacemaker procedure was completed within 10 minutes after the patient was re-sedated.

Abbott was found to be in violation of 13 safety violations, but not all were related to the fire, the Tribune reported. The accident prompted a hospital-wide fire safety investigation by the state fire marshal's office and other minor violations were discovered elsewhere, officials said.