Man burned on surgery table
A man went in for knee surgery but left with burns after his leg caught fire while he was being operated on at Wairarapa Hospital.
Health and Disability Commissioner Anthony Hill found Wairarapa District Health Board and an orthopaedic surgeon in breach of its code for failures in the care of a man during the procedure in September 2017.
The commission said the surgeon did not wait for an alcohol solution to dry before applying an electrically induced heating device to the patient. The man’s leg caught fire, leaving him with 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,’’ Hill said.
He blamed the DHB as the service operator for the fire and also said the surgeon had ‘‘failed to provide services to the man with reasonable care and skill’’.
The commissioner recommended the
DHB and surgeon both apologise to the patient and that the surgeon undertake further education and training on fire hazards in operating theatres.
Wairarapa DHB spokeswoman Anna Cardno said the board had ‘‘apologised unreservedly’’ for the injuries the patient sustained, and for the resulting treatment and rehabilitation endured.
‘‘The DHB takes full responsibility for what occurred and immediately made significant changes to practice, policy and training in order to ensure it will not happen again.’’
The health board was asked to check the implementation of its new policy that forbids the supply of any alcohol-based solution to the operating team until after diathermy was finished.
‘‘This has been implemented and a follow-up audit is scheduled,’’ Cardno said.
It also needed to prepare appropriate policies and guidelines, as well as train staff.
The surgeon who conducted the procedure said in the commissioner’s report that he was not aware of the risks of the device being using. ‘‘I can only repeat that I am very sorry he experienced such a serious complication.’’