A woman suffered burns during a cesarean operation when a fire broke out in the operating room at Sheba Medical Center in Tel Hashomer in 2008, a report by a Health Ministry inquiry committee reveals.
Hospital staff had washed the woman with various chemical solutions to sterilize her before the operation and then dried her off. But when she was brought to the operating room, the surgeon asked that the relevant areas of her body be washed down again with an alcohol solution, just to be doubly sure.
The surgeon then cut into her with a diathermic needle. But the instrument, which uses an electric current, emitted a spark, and when the spark touched the alcohol on her body, it burst into flame.
After putting out the fire and bandaging her, the staff continued the operation and delivered a healthy baby. But the woman later needed plastic surgery for the burns, including a skin transplant in her buttocks and thighs.
Following several earlier cases in which a diathermic needle caused a fire, the ministry had published rules aimed at preventing such fires. Among other things, it said the device cannot be used until the patient is completely dry - a rule evidently not followed in this case.
The inquiry committee noted that the danger of fire is particularly great during operations, like a cesarean, performed with the legs elevated, since this causes the alcohol solution to collect under the buttocks.
It also recommended that the ministry require the use of nonflammable sheets in operations involving diathermy. In the Sheba case, the problem was compounded when the sheets caught fire.
The ministry said both the surgeon and the nurse shared responsibility for the error. However, because they had cooperated fully with both the ministry's inquiry and Sheba's internal inquiry, the ministry's ombudsman decided that no steps should be taken against them beyond including the report in their personnel files.
Sheba said it had learned the lessons of the incident. It also stressed it gave the woman "optimal care until she recovered."
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