Operating Room Flash Fire Leads to Severe Burns in a 2-Month-Old Patient


This pediatric burns case involves a 2-month-old girl who required surgical repair for a heart condition. During the procedure, there was a flash fire in the operating room (OR) which manifested from alcohol vapors used to prepare the patient for sterility. The child suffered severe burns and burn-related injuries and required ICU care for an extended time period.

Question(s) For Expert Witness

  • 1. With regards to patient safety, is it beneath the standard of care to fail to follow proper protocol to eliminate alcohol vapors which can result in surgical fires?

Expert Witness Response E-004476

The joint commission has specific safety standards concerning staff training and practice in relation to surgical fires. Proper communication could and should have stressed OR safety to the physician. Nurses and nursing managers have a duty to serve as an advocate for the patient and create a safe patient environment. The care provided by the nursing and hospital staff in general most likely fell below the standard of care. This particular case may be in violation of those standards. I was a joint commission surveyor for 14 years, and have wide administration experience in hospitals.

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