Pa Patient Saf Advis 2008 Dec:5(4):110.
Letter to the Editor: Electrical Accidents in the Operating Room
Anesthesiology; Surgery
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Letter to the Editor

Patient and personnel safety in the operating room (OR) is an ever-present concern for healthcare administrators, clinical staff, and engineering support personnel. A decades-old debate has again arisen over whether there is a true need for isolated power systems in ORs.

ECRI Institute is continuing to research the incidence of medical device failures in the OR when the failure caused a shock to patients or personnel (independent of electrosurgical current issues) or when there was an alarm of the line isolation monitor (LIM) on the isolated power supply system in the room. Not all ORs in the United States have isolated power systems installed, and such systems are not mandated by code. The question as to whether installation of such isolated power systems is indicated to mitigate perceived hazards should be evaluated based on evidence of the types of adverse events that may have occurred in recent years.

The evidence base for equipment failure resulting in patient or personnel shock incidents or LIM alarm incidents appears to be almost nonexistent. We are hopeful that the extensive database at PA-PSRS may have information that can address this question.

Mark E. Bruley, BS, CCE
Vice President, Accident and Forensic Investigation
ECRI Institute
Plymouth Meeting, Pennsylvania

Editor’s Note

The PA-PSRS analysts thought that this question from one of the Pennsylvania Patient Safety Advisory editorial board members was interesting and potentially informative. We searched the PA-PSRS database on September 18, 2008, (search conducted of more than 800,000 reports submitted since 2004) for the keyword “shock” and/or the phrase “line isolation monitor” in reports from the operating room (OR). We found five reports from ORs that met the search terms criteria:

  1. Staff member reported [receiving] a shock while touching patient and anesthesia machine during the same time [surgeon] touched patient with Bovie pencil. The Bovie pencil and cautery machine [were] taken out of use immediately and replaced.
  2. While doing a cystoscopy and [a transurethral resection of the prostate] using Erbe Bovie CE 7090 [on a patient under spinal anesthesia, the] patient jumped and said felt something go up the back. At that same time, the Bovie stopped working. The Bovie cord and electrode were both changed, and the Bovie started to work. [The surgeon] said he also felt a shock in [the] finger twice. The Bovie pad site was OK. No burns were noted anywhere on body. The Bovie was taken out of service for check.
  3. While using the Trivex [light source] machine, the light appeared to not be as bright as normal. The staff tried to reposition the light cord in the machine, and in doing so a staff member was shocked. The machine sparked a few times at the light source and began to smell hot. The machine was turned off, unplugged, and taken out of service. The patient was not injured.
  4. [An employee pushed the] button on outside of OR doors for auto opening and received a large shock that could be felt all the way from arm to feet. [Another] employee also received [a] shock, holding onto the other [end] of the metal cart that the first employee was holding.
  5. KCI Air Bed SN.BKOK 01612 was wired incorrectly and set line isolation monitor off. [Appropriate person] was called and [had to rewire] it. [This] corrected the problem. The patient was free from injury.

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