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OR Fire Reveals N.Y.C. Hospital's Safety Deficit

Lack of prevention plan was "immediate jeopardy situation."

Published: May 3, 2016

A surgical fire PLAN TO PREVENT Is fire safety part of your pre-op time outs?

A New York City hospital was cited by the state for its apparent failure to implement an OR fire prevention plan, according to an article in the New York Post.

NYU Langone Medical Center showed "no evidence of an immediate plan to prevent the recurrence of fire injury to patients undergoing surgery," said a New York State Department of Health investigation, which found flawed communications between a surgeon and an anesthesiologist to blame for a December 2014 flash fire that burned a patient.

The state visited NYU Langone shortly after the fire and declared an "immediate jeopardy situation" due to what it saw as a lapse in compliance with current standards of safety practices.

For example, surgical personnel who'd worked the case "gave no details of any strategies they discussed or actions they would implement to prevent the occurrence of an actual fire," state officials wrote.

The facts of the incident were largely unavailable, as the investigation report provided to the Post was heavily censored. But the report indicated that the patient was receiving mask oxygen during the surgery, and that the anesthesiologist didn't know that the surgeon planned to use the instrument that sparked the flare-up near it.

NYU Langone took action within hours of the "immediate jeopardy" declaration, the state noted, including scheduling staff training and requiring alternative methods of oxygen delivery in high fire risk cases. The center did not respond to a request for comment.

David Bernard


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