A series of patients have reported suffering severe burns from fires while undergoing surgery at D.C.-area hospitals, according to a News4 I-Team review.
The incidents, at least four of which triggered lawsuits, date back almost a decade, but some victims and safety advocates said the frequency of the fires reveals a lack of oversight by some government agencies.
In a lawsuit filed in Fairfax County Circuit Court in late 2015, Beverly Wilson said she suffered severe burns across her face and other parts of her body from a fire in an operating room of Inova Fairfax Hospital in December 2013. Wilson’s civil suit alleged the fire started when a doctor began using an electrical surgical tool. An oxygen mask was being administered to Wilson, the suit said, and the drapes surrounding her face caught fire, triggering her face itself to catch fire. In her complaint, Wilson also said she suffered severe burns, dental injuries and post-traumatic stress disorder.
Wilson and Inova reached a settlement agreement Monday, her attorney said.
Wilson’s suit references a similar incident at an Inova hospital in Alexandria in 2005.
“During the procedure, an electrocautery unit was used concurrently with an oxygen mask, which had oxygen flowing to it,” the suit alleged. “Oxygen leaked from the mask and pooled under the drapes, which had been placed about the patient’s face. A fire erupted and the patient suffered burns to her face and head.”
Wilson’s lawsuit claims Inova designed changes in its surgical procedures after the 2005 incident, which should’ve prevented the 2013 fire.
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“Inova Hospital took steps designed to prevent operating room fires, including but not limited to discontinuing the use of oxygen face masks, lowering oxygen levels and requiring healthcare providers utilizing its operating rooms to implement a checklist of prevention steps before surgical procedures,” the lawsuit said.
In its court filings, Inova has denied many of the allegations in Wilson’s lawsuit.
“Quality care and patient safety are Inova’s top priorities as we strive to deliver the best outcomes for our patients,” the hospital said in a statement to News4.
When asked whether its surgical procedures were adjusted after the 2005 incident, an Inova spokesman said there was no absolute discontinuation of the use oxygen masks.
“Not every patient is intubated nor do nasal oxygen prongs meet every patient requirement,” he said. “While I cannot address specific patient care plans, there are circumstances when a mask is required and/or is a patient’s preference. These care plans are always developed with the patient in mind.”
The I-Team’s review found other lawsuits filed by other Washington, D.C.-area patients seeking damages for injuries suffered in operating room fires.
The patient involved in the 2005 fire, referenced in Wilson’s lawsuit, said she suffered second- and third-degree burns. Rita Talbert, of Stafford County, told News4 the fire was similar in cause and devastation to the one alleged by Wilson. Talbert said the injuries were grievous. She said she’s undergone 18 surgeries to treat her injuries.
“I still get angry,” she said. “Sometimes I just feel like going up there and standing in the hospital and say, ‘Look at me. Look what you’ve done.’”
Military veteran Steven Vince Anthony sued the U.S. Department of Veterans Affairs for a 2011 incident at the agency’s medical center in Martinsburg, West Virginia.
“When the cauterizing instrument was applied to (Anthony’s) face, it ignited the materials used in the surgery including, but not limited to, the preparation solution, the tenting materials, and the oxygen that was being administered to (Anthony),” Anthony’s suit said.
The lawsuit was settled.
Anthony said the injuries to his face and hands were severe and still cause him pain and suffering.
“If all (surgical) procedures happen the way they’re supposed to, it won’t happen,” he said. “It’s completely 100 percent avoidable.”
“The Martinsburg VA Medical Center is committed to providing a safe environment for our patients,” the U.S. Department of Veterans Affairs told the I-Team. “We are always looking for ways to improve service, care and safety at our medical center. When there are instances of care that have results outside the realm of expected outcomes, we employ all available resources to identify the issue, the cause and how to fix the issue so it will not happen again.”
Catherine Reuter said her mother suffered a similar surgical fire in 2002 at a hospital in Washington, D.C. Reuter said her mother’s face ignited, causing third-degree facial burns, when the medical team allowed surgical equipment to ignite the chemical compound they’d applied to her mother’s face.
“It’s hard to imagine being alive and being in an operating room and being set on fire,” Reuter said.
Reuter created a safety organization and website, SurgicalFire.org, to raise awareness of the risk of surgical fires. Hospitals should stage regular operating room fire drills, Reuter said. They should also undertake fire risk assessment tests before performing surgeries, she said.
“If anybody on your surgical team doesn’t know what a surgical fire is, they shouldn’t be in the operating room,” she said.
The U.S. Food and Drug Administration said hospitals are encouraged to report fires that occur in operating rooms.
The agency said a medical association, the Joint Commission, monitors the risk of surgical fires nationwide.
“An estimated 200 to 650 surgical fires -- fires that occur in, on or around a patient who is undergoing a medical or surgical procedure -- occur in the U.S. annually,” a Joint Commission spokeswoman told the I-Team.
The I-Team’s review found only some local governments require those fires be reported to health officials.
Maryland and D.C.’s health departments said they require medical providers to notify the government if a fire occurs during surgery. D.C.’s health department reported being notified of two such fires since 2005.
“In the past 10 years, Maryland hospitals have reported 13 fires in operating suites in which electrocautery has ignited pockets of oxygen, paper drapes or antibacterial scrub liquid,” a spokesman for Maryland’s Department of Health and Mental Hygiene said. “There were no fatalities with these events and generally only minor injuries were sustained.”
But the I-Team found Virginia’s state health department does not require such reporting. An agency spokesman said the Virginia Department of Health was not specifically aware of the cases involving Wilson or Talbert at the Inova facilities.
A spokeswoman for FUSE, an organization which offers educational programs about surgery and surgical equipment for medical providers, said Inova is a test center for its program.
Full statement from Inova to News4:
“Quality care and patient safety are Inova’s top priorities as we strive to deliver the best outcomes for our patients. Certainly we regret unfortunate and unanticipated outcomes when they occur, as rare as they may be. We are diligent about conducting root cause analyses following such circumstances, which are, as you know, confidential pursuant to Virginia law. The findings of these reviews guide our continuing efforts toward process improvement.
That said, please be aware that every patient’s care plan is unique based upon his or her individual requirements as well as preferences. Specifically, the quote from 2005 should not have implied or, consequently, be understood as an absolute with respect to the use of an oxygen mask. Not every patient is intubated nor do nasal oxygen prongs meet every patient requirement. While I cannot address specific patient care plans, there are circumstances when a mask is required and/or is a patient’s preference. These care plans are always developed with the patient in mind.
All Inova hospitals are accredited by The Joint Commission, which is recognized nationwide as a level of quality that reflects an organization’s commitment to meet certain performance standards. Patient safety is a critical part of our service as a healthcare provider as we seek every opportunity to meet the unique needs of each person we are privileged to serve.”
The I-Team surveyed local hospitals to check whether they regularly conduct drills to practice and simulate their response to an operating room fire:
MedStar Washington: “MedStar Washington Hospital Center conducted a comprehensive operating room fire drill in December 2015 with our OR team. The fire drill involved simulating two fire scenarios in the procedure areas. We’ll conduct another drill in the OR this fall.”
University of Maryland Medical System: “The University of Maryland Medical Center does perform OR fire drills and simulation exercises, and conducted at least a dozen drills per quarter in FY 2015.”
Adventist HealthCare, Shady Grove: “Adventist HealthCare Shady Grove Medical Center and Adventist HealthCare Washington Adventist Hospital do conduct annual fire drills in the operating rooms at each hospital. In addition, they hold annual in-service fire safety training sessions.”
George Washington University Hospital: “GW Hospital meets and exceeds recommendations regarding OR fire drills, including performing both the drills, as well as offering fire safety education.”
Frederick Memorial Hospital: “FMH held 31 fire drills in 2015, including two operating room specific drills.”
Johns Hopkins Medicine: “(JHMI) does the drills each year and also include annual training on surgical fires for relevant staff.”
Reported by Scott MacFarlane, produced by Rick Yarborough, shot by Jeff Piper and Steve Jones, and edited by Jeff Piper.