At least 10 patients at an Oregon hospital left the OR with burns, and it took months to identify the culprit: The filters on the OR's halogen lights needed to be replaced.
The first case of skin burns came to light in June 2014, according to Ray Wiley, the Silverton Hospital's Director of Quality and Risk Services.
Initially, the hospital looked at "common culprits" such as solutions used on skin before surgery, bandages, devices used to stop bleeding during surgery, or post-surgery dressings as the cause of the burns. It took five months for a hospital investigation to identify the true source of the burns.
The 761 hospitals likely to face penalties for patient harm
According to the investigation, OR staff changed the diffusers on halogen lights in September 2013, but they did not change the filters, which are necessary to keep out harmful UV light. These filters are often included in the bulb's glass, but some—like the ones at Silverton Hospital—need separate filters.
So far, about 10 patients have come forward with injuries ranging from mild burns to "thick skin burns." Wiley says nearly 2,100 patients underwent surgical procedures in the ORs during the 14-month period. They are now looking for other affected patients who may be in need of compensation for their burns.
Silverton has replaced the ORs' halogen lights with LED lamps and has altered its protocols for medical equipment maintenance. In addition, the hospital has contacted the Oregon Safety Patient Commission and plans to submit a formal report about the incident (AP/Oregonian, 1/21).
The takeaway: In the OR, halogen bulbs without filters can cause patients to sustain burns. One hospital is refining its maintenance procedures to prevent future issues after about 10 patients were burned in ORs where filters had not been replaced.