Help Solve OR Burn Mystery!!

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I have been circulating CT for 10 years and have never encountered this issue:

In the past 2 months my OR has had 6 open heart patients that present with partial thickness burns 1-4 days post op. Most of the burns have been in the right or left axilla. At first we thought it was a chemical burn from prep pooling, but we have since changed the way that we prep to ensure there is no pooling and we are still getting burns.

It has happened in 3 different ORs, 3 different surgeons, some use chloroprep, some use duraprep. We have had multiple meetings with every department involved in our patients' care and have not been able to find the cause.

Any thoughts?

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Specializes in Nephrology, Cardiology, ER, ICU.

Moved to OR nursing

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Is there a common pattern and size? If it's really a burn, it isn't occurring in the OR if they're at least one day post op. I'd start looking at the ICU.

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Is there a possible grounding issue with the bed, creating a faulty ground return? Usually the bovie would detect that and alarm, but I'm just throwing stuff against the wall here... can you check the records and see if the same bed has been moving around your OR and ended up in all these cases?

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Specializes in OR, Nursing Professional Development.
Is there a common pattern and size? If it's really a burn, it isn't occurring in the OR if they're at least one day post op. I'd start looking at the ICU.

Agree with this. Is the ICU using a warming device on these patients post op?

What are the common themes among these patients? Same ICU room? Same ICU staff? All warmed with the same device?

Has your patient safety officer been notified in addition to risk management to assist in finding the cause?

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I agree, I don't think the burns are occurring in the OR either. For some reason, the OR has been the area of focus since day one.

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No, it's been 3 different ORs with different beds and different bovies. No common equipment or staff members.

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The ICU says they do not use any warming devices. Patient safety has been involved, but has only monitored prepping in the OR.

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Reminds me of when the ICU wrote up my anesthesia group for "tape burns" on patient's faces when they were the ones ripping it off to extubate or switch from our tape to their Velcro tube holders.

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No warm IV bags.

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It's your OR lights.

Same thing was happening in Oregon three years ago.

Patients Get 'Burned' During Surgery at Oregon Hospital - ABC News

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