Cause of Device-Related Incident
*Not stated

Clinical Specialty or Hospital Department
Clinical/Biomedical Engineering; Obstetrics and Gynecology; OR / Surgery

Device Factors
*Not stated

Document Type

External Factors
*Not stated

Mechanism of Injury or Death
Burn (electrical, thermal, chemical); Fire

Support System Failures
*Not stated

Tampering and/or Sabotage
*Not stated

User Errors
*Not stated

Electrosurgery Is Dangerous


Before the procedure:

  • Examine the equipment and accessories—DO NOT USE:

Cables and accessories with damaged (cracked, burned, or taped) insulation or connectors

Gelled return electrodes* with dry or discolored areas

  • Be sure that accessories have been reprocessed and sterilized according to hospital policy.
  • Check operation of the return electrode contact quality monitor.
  • Be sure that the audible activation indicator can be heard.
  • If possible, don't place the return electrode near pacemaker leads.
  • Keep ECG electrodes far from the surgical site and the return electrode.
  • Keep electrosurgical cables away from the patient and from monitoring cables.
  • Avoid accumulating pools of prepping agents and other fluids around the patient.
  • Don't spark the active electrode** to ground or to the return electrode.

During the procedure:

  • Don't continue to increase power settings if you aren't getting results—look for other problems.
  • Place active electrodes in holsters when not in use.
  • Observe appropriate fire precautions when using O2, N2O, or flammable prepping agents, especially in head and neck surgery.
  • Activate the unit only when ready to deliver electrosurgical current.
  • Avoid prolonged activation.
  • Use the lowest effective ESU output setting.
  • Check contact with the return electrode after repositioning the patient.


* Also called ground plate, patient plate, butt plate, grounding pad, or dispersive pad electrodes.

** Also called pencil, blade, knife, loop, ball, or active handle electrodes.

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