Fire Caused by Improper Disposal of Electrocautery Units
Hazard [Health Devices Mar 1994;23(3):98]
A member hospital experienced a small trash fire when an electrocautery
unit was discarded in a surgical refuse bin without the proper safety cover in place
over the tip and activation switch. The weight of additional refuse placed on top of the
unprotected unit activated the ON switch, causing the cautery tip to heat to a temperature
sufficient to ignite a trash fire.
The device used in the reported incident was a disposable, battery-powered,
hand-held electrocautery unit. This unit is a small, thin, cylindrical (i.e., penlike)
device with an activation button (designed to be pressed by the surgeon)
mounted on one side of its body. Because this design is common to many
similar units, users of all such devices should follow our recommendations, below.
- Keep safety caps for all disposable electrocautery
units used during surgical procedures, and replace the cap before disposing
of the unit.
- Carefully cut or remove the cautery tip with scissors, large metal
hemostats, or pliers before disposing of the device. Avoid activating the
electrocautery unit during dismantling.
Electrocautery Units, Battery-Powered [11-421]
Cause of Device-Related Incident
Device factor: Design/labeling error
User error: Incorrect clinical use
Mechanism of Injury or Death