CA says low humidity raised the risk of surgical fires, leading to $100K fine

Hospital Safety Insider, April 14, 2010

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California health officials this week punished hospitals that have allegedly run afoul of regulations, including one facility that raised the risk of fires in a labor and delivery OR.

According to records reviewed by the California Department of Public Health, three scheduled Caesarean sections were performed at Southwest Healthcare System in Murrieta on October 26 and 28, 2009, despite low humidity levels noted earlier on those days in the surgical suites. Low humidity in an OR increases the risk of fire from sparking surgical instruments, much like dry days can raise the potential for brush fires.

The state said the alleged lapse constituted an immediate jeopardy to patient safety, and issued a $100,000 penalty against Southwest Healthcare.
Corrective actions taken by the hospital include:
  • Developing a new OR humidity monitoring log
  • Revising its temperature and humidity policy to better gauge low humidity levels and increase communication between clinicians and plant operations staff
  • Checking humidity levels before each surgical procedure, instead of just prior to the first case of the day
Case logs for three Caesareans performed on October 26 and 28 indicated that humidity was between 22% and 25% for the surgeries, the state said.
The hospital’s policy on humidity monitoring indicated the range should be from 35% to 60%, according to the state’s report.
Southwest Healthcare has requested a meeting with the state to dispute the findings, as it argues the records reviewed by investigators were incorrect about low humidity levels during two of the Caesareans, as the levels had been increased by facilities staff prior to the surgeries.
The hospital acknowledged one Caesarean was conducted at 22% humidity, but pointed to research by the American Society of Heating, Refrigerating, and Air-Conditioning Engineers indicating that levels as low as 20% don’t contribute to fire risks in ORs.
Look for much more about this debate in the upcoming issue of Healthcare Life Safety Compliance, the only monthly newsletter in the country dedicated to covering fire protection issues in hospitals.

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