Investigating Device-Related Skin "Burns"

Despite a great deal of care and concern by medical, nursing, surgical, and engineering staff, patients continue to suffer inadvertent skin injury in the operating room (OR) and in special care areas (e.g., intensive care units ICUs, cardiac care units CCUs) of the healthcare facility. These injuries can prolong morbidity and extend hospitalization, appreciably increasing medical costs to the patient and healthcare facility. The facility and the surgical team may also face liability costs if the injured patient brings suit.

______________ * This guidance article is derived from a guidance article in the December 2005 issue of ECRI's Health Devices journal. For more information on Health Devices, contact ECRI's communications department by e-mail at communications@ecri.org. ______________ Although certain medical procedures (e.g., electrosurgical procedures) are known to present the risk of causing device-related burns or other accidental skin injuries, it is important that staff not rush to judgment about the nature or cause of any such injuries that do occur. In its 35 years of investigating patient injuries and deaths from errors and accidents involving healthcare technology, instruments, devices, and systems, ECRI has observed that skin injuries are not always what they seem.

Medical devices are frequently blamed for accidental skin injuries. While such injuries may have the appearance of a full- or partial-thickness burn, thermal or electrical sources are not always involved. In many cases, the injury may be an abnormal or idiosyncratic physiologic response to otherwise normal conditions of use and performance of that device. Alternatively, the injury may be due to pressure necrosis, an adverse drug reaction, or a disease process that happens to develop in the area where a device was applied. (See Etiologies of Accidental Skin Injuries. ) It is therefore misleading (and in many cases inaccurate) to refer to an injury...