Citation

Wolff KB, Soncrant C, Mills PD, Hemphill RR. Am. J. Med. Qual. 2016; 32(4): 445-452.

Affiliation

National Center for Patient Safety (NCPS), Ann Arbor, MI.

Copyright

(Copyright © 2016, American College of Medical Quality, Publisher SAGE Publishing)

DOI

10.1177/1062860616658343

PMID

27401082

Abstract

The objective was to analyze reported flash burns experienced by patients on home oxygen therapy (HOT) in the Veterans Health Administration (VHA) using a qualitative, retrospective review of VHA root cause analysis reports between January 2009 and November 2015. Of 123 cases of reported adverse events related to flash burns, 100 cases (81%) resulted in injury, and 23 (19%) resulted in death. Although 89% of veterans claimed to have quit smoking (n = 109), 92% (n = 113) of burns occurred as a result of smoking. The most common root cause was risk identification issues. Recommended actions were standardized risk assessment policies, patient education, and the adoption of fire stop valves. Patients with a history of smoking who are on HOT should be considered for fire stop valves and offered consistent counseling and follow-up using a combination of harm reduction and shared decision-making techniques. Standardization of risk identification and documentation is recommended.

© The Author(s) 2016.

Language: en