Jump to content

Help Solve OR Burn Mystery!!

Operating Room   (2,736 Views 19 Comments)
by a.smithrn a.smithrn (New) New

188 Profile Views; 6 Posts

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?

Share this post


Link to post
Share on other sites

traumaRUs has 27 years experience as a MSN, APRN, CNS and specializes in Nephrology, Cardiology, ER, ICU.

166 Articles; 21,045 Posts; 191,589 Profile Views

Moved to OR nursing

Share this post


Link to post
Share on other sites

1 Follower; 1,319 Posts; 12,295 Profile Views

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.

Share this post


Link to post
Share on other sites

222 Posts; 5,517 Profile Views

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?

Share this post


Link to post
Share on other sites

Rose_Queen is a BSN, MSN, RN and specializes in OR, education.

5 Followers; 4 Articles; 8,916 Posts; 104,632 Profile Views

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?

Share this post


Link to post
Share on other sites

6 Posts; 188 Profile Views

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.

Share this post


Link to post
Share on other sites

6 Posts; 188 Profile Views

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

Share this post


Link to post
Share on other sites

6 Posts; 188 Profile Views

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

Share this post


Link to post
Share on other sites

1 Follower; 1,319 Posts; 12,295 Profile Views

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.

Share this post


Link to post
Share on other sites
×