Defibrillator Sparks Oxygen Causing a Fire as Medical Staff Attempt CPR on Patient
Police and fire officials report that a fire broke out after a 70-year-old patient’s heart stopped, and medical personnel responded and used a defibrillator (AED) to try and resuscitate the patient. The defibrillator sparked and then ignited oxygen in the room due to a valve being left on. The patient could not be revived and received burns to his shoulder and back; however, the medical team reported to police that the patient had died before the fire happened.
A similar AED device with an operator’s manual included this printed out stipulation: “Do not use the Samaritan pad near flammable gases or compressed oxygen.”
The hospital initially issued this statement: “A small fire involving a piece of equipment occurred at this hospital” and an investigation “concluded there were no adverse impacts to patient outcomes as a result of this accident.”
Fire officials issued a report citing the defibrillator as the cause of the fire, the reason for the burns on the patient, and damage to equipment in the room. After the fire official’s report, other documentation, and information from the 911 calls were obtained, the hospital issued another statement. It read: “We reported the incident to authorities and conducted an internal review to help ensure this does not happen in the future. The safety of our patients is a high priority for us. We regret this incident occurred but are grateful to our staff for reacting quickly in extinguishing the fire and continuing to care for patients.”
The family of the patient was unwilling to talk to the news media about the incident.
Compliance Perspective
Failure by a facility to ensure that medical staff are trained on the use of a defibrillator and the potential for causing a fire if used near oxygen or flammable gases might be considered provision of substandard quality care with immediate jeopardy, in violation of state and federal regulations.
Discussion Points:
- Review policies and procedures regarding use of defibrillators in areas where oxygen and flammable gases are located.
- Train staff regarding the importance of making sure that all oxygen valves are turned off when not in use, and remind staff of the fire potential when a defibrillator is used near oxygen and flammable gases.
- Periodically audit residents’ rooms to determine if there are instances where oxygen is not in use, but the valve is not turned off. Also consider placing a written warning on defibrillator devices reminding users of the potential for fire if used near oxygen and flammable gases.
