Communication Breakdown Leads to Patient Burn


Dear Readers,

When a breakdown in communication among the surgical team occurred at the end of a procedure, the patient suffered a second-degree burn.

The Operating Room (OR) is a busy environment, where teams are carefully managing many priorities to ensure the best patient care. In this case, although the joint surgery went smoothly, a hot light came in prolonged contact with the patient, causing the burn.  Patients who are under sedation or general anesthesia are especially vulnerable, and we must do everything possible to keep them safe.

The take-away from this story: When procedures are conducted by teams that do not frequently work together, the importance of clear communication and protocols is even greater.

For team members to carry out their roles with the utmost precision and care, they need to be supported by continually improved communication methods and protocols.

Thank you for reading,




What Happened

A surgeon was using an arthroscope (an instrument that inspects the interior of a joint) that has a light attached to the end of it. After the surgeon was done, the surgeon handed the arthroscope to the scrub tech. The light was still on. The surgeon thought that the scrub tech would ensure that the light, which gets hot very quickly and can cause burns, gets turned off (by asking the circulating nurse to do so) and then place it on a sterile table near the operating field.

The scrub tech, however, did not realize the light was on and put the arthroscope on the table. After the surgery was over, and while the team was removing the surgical drapes that were covering the patient, the team noticed that the light had become detached from the arthroscope. Moreover, the light was on the drapes and there was a burn hole right next to it. The team promptly turned the light off and examined the patient, finding a second degree burn on the patient’s arm.

The team immediately treated the burn and when the patient awakened, apologized to the patient, disclosing what had occurred. The patient understood, and fortunately, recovered from the burn within a few weeks.

What Went Wrong

When the surgeon no longer need the arthroscope handed the arthroscope to the tech, the surgeon thought the next steps (to make sure the light was off before putting the arthroscope on the table) were clear. In other settings in our system, where this procedure is frequently done, this is how it works.  However, this procedure was being done with a team that usually does not perform these procedures together.  And no one was specifically assigned the task of ensuring the light was turned off. This is why the surgeon did not feel the need to announce the light should be turned off, and the tech or circulating nurse did not ask about the light still being on.

When using any lighted instrument, there is potential for harm; therefore, best practice is to hold the instrument or to turn off the light when not in use.

What We Are Doing

We conducted a review to determine potential gaps in clinical practice and are working on:

  • Improving Communication: This case illustrates how communication could be improved by specifically always asking that the light be turned off and by using closed-loop communication. One of the especially effective ways we educate surgical teams about the importance of closed-loop communication is through training in the Neil and Elise Wallace STRATUS Center for Medical Simulation at BWH. “In teaching the concept of closed loop communication, we ask staff to always use names to make it clear who you are talking to, have the receiver repeat back the request and the initiator close the loop,” says Doug Smink, MD, MPH, associate medical director of STRATUS, noting that 50 teams so far have completed the five-hour sessions. “This training will touch almost everyone who works in the OR.”
  • Improving Protocols: We are also working to make sure that all staff members understand that they should confirm that the light is off before setting it down when it may no longer be needed. This would mean that in a case like this one, even if the surgeon did not state what should be done with the light, the tech would ask now what should be done about the light.

Constantly Monitoring for New Equipment: The BWH Biomedical Engineering team, which investigated the light source to ensure it was functioning properly, is monitoring the industry for the release of new and improved light sources that are equally effective but not do not get as hot, which can help decrease the risk of burns. This could help provide a fail safe when human errors in communication and protocol breakdowns occur.