Robert Michael: Hospital corrects nursing policy regarding pre-operative practices

Inner Circle member Robert Michael, Rockville, Maryland, represented a woman who was severely burned during tracheotomy surgery.  She had been prepped with an alcohol-based surgical sterilization solution and tented with surgical drapes.  When the electrical surgery instruments were turned on, the solution ignited causing a colorless flame that remained unnoticed until the surgery team noticed the smell of burning flesh.  The woman awoke from the anesthesia with 2nd and 3rd degree burns on her face, neck, and head.  As part of the case resolution, the hospital agreed to implement a new nursing policy requiring that the patient be checked for pooling of the surgical prep in skins folds and that the bedding be checked for any run-off accumulation prior to the onset of surgery.

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