OPSC Patient Safety Minute | Preventing Burns from Light Sources
Burns from light sources in laparoscopic, thoracoscopic, or arthroscopic procedures are a documented patient safety issue. In April of 2023, The Joint Commission (TJC) released “Quick Safety Issue 69: Preventing Light Source-Related Burns from Laparoscopy and Arthroscopy.” Acute care facilities here in Oregon have shared some additional lessons related to burns, smoke, or fires resulting from light sources and devices through the Patient Safety Reporting Program (PSRP).
Insight from Oregon Facilities
The events submitted to PSRP demonstrate that Oregon facilities understand the risk of burns and fires from these devices. The facilities who reported to PSRP agree that the most important recommendation is to keep light cords away from anything that could be burned, like a patient's skin, surgical drapes, and other flammable materials.
About two-thirds of the reports submitted to OPSC on this topic were related to a device, light source, or cord being set on a surgical drape or directly on the patient. Most of the reports shared that they had an agreed-upon safe location on which to set down any kind of device that could burn the patient or set something on fire. Many also had an alternate safe location. But there were several cases where the safe place or alternate safe place wasn’t used, either because it wasn’t big enough or it couldn’t be reached. In a few cases, the person tasked with managing the device when not in use wasn’t always able to visualize these safe places when in the operating room.
“[The] most important recommendation is to keep light cords away from anything that could be burned…”
What You Can Do to Prevent Burns from Light Sources
Review the “safety actions to consider” in Quick Safety 69, and think about what might prevent them from being followed—your surgical teams are working hard to do the right thing, the right way, every time, and they need more than just reminders to make it happen.
Incorporate human factors analysis into your solution planning. Is there space in the room? How do people actually move around that space? Are the safe places and alternate safe places accessible? You might also consider asking:
When you adopt a new device, do you do usability testing?
Do you do any follow-up usability testing over time to understand how practice changes?
When you adopt a new device, do you do simulation testing?
Do you use simulation training to identify opportunities for adverse events to occur?
Continue to report these events to the FDA (Food and Drug Administration) when they occur. The more information the FDA has, the better they can work with manufacturers to make the kinds of engineering changes to devices (like better insulation and different materials so that cords don’t overheat) needed for consistently safe care.
Resources
The Joint Commission. 2023. “Quick Safety Issue 69: Preventing Light Source-Related Burns from Laparoscopy and Arthroscopy.” The Joint Commission. April 2023. https://digitalassets.jointcommission.org/api/public/content/0abe575b38ec435584f880203d305503?v=cd08af33
Center for Devices and Radiological Health. 2022. “Human Factors and Medical Devices.” FDA. May 2, 2022. https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/human-factors-and-medical-devices.
Daniels, Tressa, Tim Goldsmith, and Anindya Basu. 2021. “Overview of a Robust Human Factors Engineering Process.” Biomedical Instrumentation & Technology 55 (1): 16–20. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8641423/.
