Causes And Effect Of Burns

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Root Cause Analysis of Burns caused in OR Name: Abbiramy Arumugam Course: BME 5030 PROJECT SUMMARY This paper discusses the root cause analysis of burns that occur in procedural and operating rooms. The Cause Mapping method is used as the primary technique to investigate the two specific incidents reported in the operating room. The cause and effect principle is the basis of this technique and this method can be applied to situations of varied severity levels. Patient burns caused by light scopes in procedural and operating rooms is an example of safety, compliance and customer issue and this approach of Cause Mapping is very effective in investigating such issues. Root Cause Analysis…show more content…
But it was still on. The resident Nurse noticed the light source when she went to put off the alarming electrocautery unit. At that point the light source was immediately switched off, but it had been touching the patient’s skin which resulted in blisters of 4mm in the right inguinal area. Severity Level 2-Temporary /minor harm Stage -1 Burn. Case #2 Orthopedics Surgery The light source has burned through the drape. The patient arm showed a minor discoloration though no skin breakthrough was noticed. Severity level 2-Temporary/minor harm. Stage 2 burn. The stakeholders for this root cause analysis of the burns caused to patients because of unattended light sources were identified. The stake holders are resident nurses of general surgery and specialty surgery areas, Biomedical Engineer, Risk Manager. Use of Light scopes in Surgery The most important components of a laparoscopic system are the light source and light cable. The light cable is mainly available in two types the fiber optic cable and gel-filled cable. A gel-filled cable the transmitting channel is filled with clear liquid optical gel. A fiber optic cable transmits light through internal reflections within glass fibers. High temperatures produced in the system depends upon many different factors such as the type of light cable, the type of light bulb used as the light source, the heat dissipation mechanisms, the heat filters used. The gel filled cables are capable of transmitting
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