Cause of Device-Related Incident
Device factors; User errors

Clinical Specialty or Hospital Department
OR / Surgery

Device Factors
Design / labeling error

Document Type
Hazard Reports

External Factors
*Not stated

Mechanism of Injury or Death
Fire

Support System Failures
*Not stated

Tampering and/or Sabotage
*Not stated

User Errors
Incorrect clinical use

UMDNS
Electrocautery Units, Battery-Powered [11-421]

Fire Caused by Improper Disposal of Electrocautery Units



Hazard [Health Devices Mar 1994;23(3):98]

Problem

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.

Conclusions

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.

Recommendations

  1. Keep safety caps for all disposable electrocautery units used during surgical procedures, and replace the cap before disposing of the unit.
  2. 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.

UMDNS Term

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

Fire


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