Burns and Fires from Electrosurgical Active Electrodes
Hazard Update [Health Devices Aug-Sep 1993;22(8-9):421-2]
For more than 20 years, ECRI has warned users about problems related to
inadvertent activation of electrosurgical unit (ESU) active electrodes. Inadvertent
activation typically occurs when a surgeon places an ESU electrode on the patient or
surgical drapes between intended ESU activations and a device malfunction or unintentional
switch activation causes the device to become energized, resulting in a burn or fire. (For
assistance in investigating such incidents, see our Guidance Article "Investigating
Although we have repeatedly recommended the use of clearly audible
activation tones and safety holsters, we continue to receive problem reports and to
conduct accident investigations related to inadvertent ESU electrode activation. This has
prompted us to update our previous reports and to reemphasize the need to use safety
features and precautions.
Most currently available ESUs have an adjustable audible activation tone
that, except on a few units, cannot be adjusted below clearly audible levels. In our
investigations of active electrode burns, we have often encountered second- and
third-degree burns that required surgical treatment. Use of an audible activation tone can
prevent such burns or at least minimize the severity of injury.
Some surgeons oppose the use of an activation tone because it is
irritating or can upset conscious patients undergoing surgery. However, no exceptions
should be made to the use of this critical safety feature. Surgeons should be made aware
that disabling the tone significantly increases the probability of accidental
electrosurgical burns and associated malpractice claims. Explaining the tone to conscious
patients should reduce their anxiety, and some surgeons provide patients with headphones
to mask disturbing noises, including audible activation tones. This can be especially
useful for delicate procedures, during which a surgical mishap could result if a patient
is startled by electrosurgery or other OR sounds.
However, the best way to prevent burns from inadvertent ESU activation is
to always place unused electrosurgical electrodes in well-insulated safety holsters, which
provide a convenient storage location for electrodes that are not in use. Even with an
audible activation tone, a brief accidental activation of an active electrode can arc
through surgical drapes, causing immediate ignition of the drapes or of latent vapors from
flammable prepping agents or ointments. ECRI has investigated numerous surgical fires that
were started in this manner.
Although most electrosurgical electrodes can be purchased with prepackaged
safety holsters, many hospitals, unfortunately, neglect to use them. Also, the recent
increase in minimally invasive surgery has increased the use of longer ESU active
electrodes that can be used inside a laparoscope or other endoscopic device, and these
longer electrodes do not fit in most safety holsters.
However, the concern about inadvertent activation with these or any
electrodes still exists. The surgeon can place the electrode on an instrument tray or Mayo
stand away from the patient or surgical drapes; if the surgeon insists on placing the
electrode on or near the patient or drapes, the active electrode cable should be
disconnected from the ESU to eliminate any risk of burn or fire from inadvertent
activation while the electrode is not in use.
- Remove from service and replace all ESUs that lack
audible activation tones. Also, replace units that have adjustable
activation tones; alternatively, contact the ESU manufacturer, and request
that the minimum volume setting be modified to ensure that it remains at an
- Always place unused ESU active electrodes in a safety holster. If using
a holster is inconvenient or awkward (e.g., when using endoscopic
electrosurgical electrodes), place the electrode away from the patient and
surgical drapes on an instrument tray or Mayo stand; if this is not
possible, disconnect the active electrode cable.
References from Health Devices:
Electrosurgical unit activation tone control [hazard report], 14(13),
Hand-switched electrosurgical active electrode pencils [evaluation],
15(6), June 1986.
Investigating device-related "burns" [guidance article], 22(7),
"The patient is on fire!" A surgical fires primer [guidance
article], 21(1), January 1992.
Using holsters to prevent electrosurgical burns [article within
evaluation], 15(6), June 1986.
- Electrosurgical Units [11-490]
- Electrosurgical Units, Bipolar [18-230]
- Electrosurgical Units, Monopolar [18-299]
- Electrosurgical Units, Monopolar/Bipolar [18-231]
- Electrodes, Electrosurgical, Active [16-860]
- Electrodes, Electrosurgical, Active,
- Electrodes, Electrosurgical, Active, Hand-Controlled [11-499]
Device factor: Design/labeling error
User errors: Inappropriate reliance on an automated feature; Incorrect control settings
Support system failure: Error in hospital
Mechanism of Injury or Death