Accidental Surgical Burns: A QI Project With a New Device

Abstract

Background

Surgical fires are events when a fire, flame, or ignition occurs in, on, or near a patient who is undergoing a procedure in an operating room or procedural area and should be considered never events. Burns from surgical fires can result in harm, lasting debility, or death. As surgical fires are considered preventable, implementation of mitigation strategies is essential.

Purpose

The purpose of this interdisciplinary quality improvement project was to determine if use of a safety cover made of silicone with a ceramic cap to shield the fiber-optic cable tip would prevent surgical fires during endoscopic procedures.

Methods

A Plan-Do-Study-Act method was used during this project.

Results

Since this project began, there have been no surgical fires or patient burns attributed to use of fiber-optic light with the GloShield product.

Conclusion

The GloShield device decreases the risk of injury from thermal burns.