Safe Cardiac Ablation Includes Careful Dispersive Electrode Placement

ECRI Institute's Accident and Forensic Investigation (AFI) Group provides specialized services to investigate, analyze, and prevent incidents, injuries, and deaths related to medical device failures and organizational systems and processes. This column discusses risk management implications of cases from the AFI Group archives.

In a routine case of cardiac ablation, an ablation catheter electrode is used to ablate various target sites in the heart and a dispersive electrode is placed on the patient's body. Both are connected to an electrosurgical unit (ESU) that provides a radio-frequency (RF) current (typically 0.5 to 1 MHz) to ablate the tissue in contact with the active electrode. In the case presented here, the patient received a severe electrosurgical burn associated...