Abbott patient burned during surgery

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

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

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, said Darcy Miner, director of compliance monitoring for the Minnesota Department of Health.

Abbott reported the incident to the 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.

It is the second unusual fire involving hospital patients in the Twin Cities this year.

The first occurred in January when a newborn baby was burned when his oxygen hood caught fire at Mercy Hospital in Coon Rapids. The baby, Maverick Werth, has recovered from second- and third-degree burns on his face and body.

In the June 24 incident, 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. Both were quickly removed, and the fire extinguished, but she was burned on her nose, shoulder and face.

A nurse present at the time said he put out flames on the patient's pillow. The patient woke up from her sedation and he waited until she calmed down before re-sedating her. The pacemaker procedure was completed within 10 minutes.

The surgeon and the nurse told investigators that a device normally used to properly drape sterile sheets around patients' faces is not available in that particular operating room. The sheets were draped high on either sides of the bed, and taped to an X-ray machine and the patient's IV pole. The surgeon said he probably did not put the cauterizing tool back in its holster between uses, which is also a violation of hospital safety protocols.

The surgeon said he has done many pacemaker procedures in that room without the draping device. Allina spokesman David Kanihan said that since the Health Department's investigation, the proper devices have been made available in that operating room.

Abbott was found to be in violation of 13 safety violations, but not all were related to the fire. 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.