The Board was notified of a professional liability payment made on 7/17/2015.

In preparation for the removal of a lipoma on a patient’s posterior neck, the surgery area and the hairline were treated with an alcohol based antibacterial solution called DuraPrep.  Although the manufacturer’s recommended drying time is two to three minutes, the general surgeon allowed the DuraPrep to dry for approximately ten minutes.  The general surgeon also blotted the patient’s neckline with a sponge.  Seeing no visible residue on the blotting sponge, the patient’s head was covered with a drape.  During the procedure, which was performed using open oxygen under monitored anesthesia care, strands of the patient’s hair covered with DuraPrep solution residue were ignited from the electrocautery.  The oxygen, which had accumulated under the drapes, served as a fire accelerant.  The patient was transferred by air with an endotracheal intubation to a burn center for flash burns to the midface, nose, mouth, eyelids, and right ear.

The Board believed the general surgeon responded appropriately to the intraoperative emergency and noted that the general surgeon sustained second degree burns to his hand trying to extinguish the flame.  The Board also acknowledged the general surgeon and his operating team’s rapid response minimized harm to the patient.

The cause of the fire was multifactorial; however, the Board believed the surgeon was ultimately responsible for the patient’s safety during the operation.  They recommended that in similar cases, the general surgeon should use a non-alcohol based skin prep, allow additional drying time, or use a non-sparking cautery, minimize the use of open oxygen, and use draping techniques that would allow adequate ventilation when open oxygen is used.  The Board acknowledged that the general surgeon received additional training in surgical fire prevention and safety.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina

Date: October 2016

Specialty: General Surgery

Symptom: Mass (Breast Mass, Lump, etc.)

Diagnosis: Post-operative/Operative Complication

Medical Error: Procedural error

Significant Outcome: N/A

Case Rating: 5

Link to Original Case File: Download PDF