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Burns sustained during surgery

Health and Disability Commissioner Anthony Hill today released a report finding Wairarapa District Health Board (DHB) and an orthopaedic surgeon in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care provided to a man during knee surgery.

During knee surgery the surgeon applied Betadine with alcohol on the edge of the man’s wound to minimise the risk of infection. The surgeon then applied diathermy without waiting for the alcohol solution to dry first. As a result, the man’s leg caught fire and he sustained burns.

At the time of the incident, DHB staff had a limited awareness of the risk of fire during surgery, and there was a lack of appropriate guidance in the DHB’s policy in relation to fire hazards. Mr Hill considered that the fire was a service failure directly attributable to the DHB as the service operator.

The surgeon failed to follow the DHB’s guideline regarding the use of alcohol-based solution and diathermy. While the guideline did not discuss specific fire hazards, it did state that alcohol-based solutions must not have contact with diathermy plates. The surgeon failed to follow the guideline by allowing the diathermy plates to make contact with the alcohol-based solution. Mr Hill found that the surgeon failed to provide services to the man with reasonable care and skill.

Mr Hill recommended that the DHB and the surgeon apologise to the man. Mr Hill recommended that the surgeon undertake further education and training on fire hazards in operating theatres. Mr Hill recommended that the DHB confirm the implementation and effectiveness of its new policy that forbids the supply of any alcohol-based solution to the operating team until after diathermy has been disabled, prepare a fire hazard policy, audit compliance with the Aseptic Technique Surgical Skin Preparation Clinical Guideline, and arrange training for its staff on the fire hazard policy and the guideline.

The full report for case C17HDC02431 is available on the HDC website.

4 November 2019


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