醫療機構火災意外

1. 慈濟綜合醫院 品管中心執行長 李毅醫師 醫療機構火災意外

2. Jersey General Hospital Fire 18th July, 1859

4. 2005年12月15日中國遼源市中心醫院的大火造成39名住院病人死亡，事後當局將該院院長、副院長依失職罪起訴。2005年12月15日中國遼源市中心醫院的大火造成39名住院病人死亡，事後當局將該院院長、副院長依失職罪起訴。

5. 2006年，莫斯科第17醫院發生火災， 造成45名病人死亡

6. 近年醫院火災 • 94年度： • 94.01.25 埔基醫院空調機房：電線走火 • 94.02.08 台東馬偕醫院放腫科直線加速器ups散熱不良(易燃物品不當堆放) • 94.12.17 高雄長庚醫院放腫科模型室：易燃品不當堆放

7. 95年度： • 95.05.23 高雄義大醫院美食街：電線走火 • 95.06.09 霧峰澄清醫院管道間：配電盤 • 95.06.29 台北馬偕醫院地下一樓：電線機房 • 95.09.25 署立台東醫院精神科病房：電線走火

8. 96年度： • 96.04.02中國附醫廚房：爐火引燃食用油 • 97年度： • 97.03.08 中國附醫停車塔：消防檢修作業失誤 • 97.06.13 林口醫院：管道間縱火 • 97.12.17 台大醫院開刀房：電線走火

9. 98年度： • 98.1.10 馬偕醫院開刀房：電線走火 • 98.1.11 中山附醫地下室：照明配電盤冒煙 • 98.3.15 中國附醫心導管室：配電盤電線短路 • 98.5.3 新光吳火獅紀念醫院地下2樓資料室起火

10. Fires in the operating roomby Yale D. Podnos, Irvine, CA, and Russell A. Williams, MD, FACS, Orange, CA the Bulletin of the American College of SurgeonsVol. 82, Number 8August 1997 • In the United States, there are approximately 2,260 reported hospital fires per year, resulting in about one death and 130 injuries. • Of these, between 20 and 30 % occur in the operating room. Historically these figures were much higher.

11. 台灣病人安全通報系統(TPR)火災事件分析 • 2005年至2009年6月: 已收案之醫療機構公共意外事件共1,063件，其中火災有126件 • 2008年至2009年6月 已收案之火災意外則有63件，其中5件對病人造成傷害，中度傷害1件及輕度傷害2件。

12. 原因 63件火災通報事件中，77.8％機構內有訂定公共意外事件應變流程(49件)， • 發生可能原因部分，以與器材設備相關因素為最多，共45件， • 又以器材設備操作不當為最多，共18件， • 其次為器材設備故障16件， • 器材設備未定期保養亦有11件。

13. 原因 63件火災意外中， • 以電線走火17件為最多， • 其次為微波爐使用不當15件、 • 病人或家屬不當行為13件(在病床上抽菸、以酒精膏煮食物、隨意棄置未熄滅菸蒂)， • 因電器故障起火有7件， • 醫療人員使用器材不慎引起之火災(如滅菌鍋、熱敷帶乾燒，將加熱器材置於易燃物品上等)有4件。

14. 案例一 • 家屬發現床頭後牆壁插座突冒黑煙並起火燃燒，立即拉鈴通知護理站，護理師立即聯絡中控室維修人員並關閉室內照明電源，並以滅火器滅火，查看後插座已燒毀，周邊牆壁燻黑，幸無人員受傷。原插座缺乏面版保護蓋，線路外露，加上線路老舊，可能因而造成走火。已加保護蓋處理，並檢查其他插座。

15. 案例二 • 病友曾因躲在棉被中抽菸點燃床單而引發火災，經制止後已加強防範。但因菸癮大，於○月○日破壞消防栓取出電線，將消防栓電線接於病室插孔內，進行觸電導火，成功後，燃燒紙箱及報紙製造煙霧，然後吸取煙霧來解菸癮，因煙霧漸大產生異味且逐漸蔓延，護理人員發現後，立即前往撲滅並通知主治醫師，前往處理的同仁因吸入煙霧略感不適，且病人於點火過程中亦有輕微灼傷紅腫。經主治醫師評估後，開立戒菸貼片每天使用。

16. 案例三 • 執行手術前備妥電燒機，病人左側貼上全新電燒導電片（單極迴路版），以75％酒精性優碘為病人消毒，消毒範圍由前頸至前胸乳線，並鋪無菌布單。完成後，固定手術用物：抽吸管、電燒筆，執行電燒筆測試。以75％酒精紗布擦拭劃刀部位，並用乾紗布再擦拭一次。劃刀皮膚層約1.5公分，拿取電燒刀進行切割止血時，接觸病人第一時間，主刀醫師及助手驚覺溫度急速升高，立刻放棄手中電燒筆，隨即發現有煙冒出，病人所戴的不織布手術帽著火，立即掀起無菌布鋪單散熱及脫下帽子，結果造成病人後頸部、雙耳廓、肩膀、背部及肩胛骨（約40*20CM）深二度灼燙傷，燙傷面積為13.5％。

17. 醫策會2005年迄今收集27件與使用電刀、電燒有關之病人燒傷、產生火花點燃無菌布、紗布，甚至起火燃燒之事件。醫策會2005年迄今收集27件與使用電刀、電燒有關之病人燒傷、產生火花點燃無菌布、紗布，甚至起火燃燒之事件。 • 美國緊急醫療照護研究機構(Formerly the Emergency Care Research Institute；ECRI)調查發現，美國每年約有550～650件手術中火災事件。

18. Most surgical fires occur in or on the patient. The most common location of surgical fires are:

19. During the period of April 2003 to February 2005 Tyco Healthcare Valleylab kept statistics on the number of surgical fires reported by health-care facilities. A total of 51 fires were reported:

20. Root Causes of Fires ::

21. The Fire Triangle ::

22. Ignition Sources :: Electrosurgical unit Electrocautery unit Laser Sparks — tissue embers

23. Ignition Sources :: Heat-producing devices High speed drill/burrs/saws Cardiac defibrillators Light sources Fiberoptic light cables

24. Fuel Sources :: In or On the Patient Hair Gastrointestinal gases Gases in surgical smoke

25. Hydrogen and methane are extremely flammable gases produced by bacteria in the gastrointestinal tract in quantities of up to 200 ml per day. • Forty percent of these gases are contained in the large bowel. Human flatus contains approximately 44 percent hydrogen and 30 percent methane. • If in an environment of at least 5 percent oxygen, hydrogen can explode at concentrations of between 4 percent and 72 percent, while methane can explode at concentrations of between 5 percent and 15 percent. • In the colon the concentration of oxygen is approximately 5 percent, but this level is increased when oxygen or nitrous oxide is administered during anesthesia.

26. Fuel Sources :: • Prepping Agents • Alcohol • Alcohol solutions- Up to 74% alcohol- Flammability warnings- Must dry 2-3 minutes * In ECRI's surgical fire update published February 2006, alcohol-based surgical preps were reportedly involved in 4 percent of surgical fires.

27. Fuel Sources :: • Operating Room Attire • Barrier Materials should resist combustion • Burn or melt when subjected to oxygen accelerant • ALL materials burn more vigorously in the presence of oxygen

28. Fuel Sources :: Supplies Mattresses, pillows Blankets, sheets, towels Sponges, tape, ace bandages, stockinet, steridrapes Gloves Blood pressure cuffs Tourniquets Stethoscope tubing

29. Fuel Sources :: Red rubber catheters Pencil tip protectors Other material mistakenly used as insulator

30. Fuel Sources :: Anesthesia components carry enriched oxidant gases! Breathing circuits Masks and airways Laryngeal Mask Airway Endotracheal tubes

31. Oxidizers :: Oxygen Oxygen-enriched atmosphere = O2 above 21% Nitrous Oxide Thermal decomposition of N2O can supply oxygen for a fire

32. Preparing for Fires :: • Locate and test gas shutoff valves and circuit breakers • Evaluate traffic patterns • Note location and accessibility of fire extinguishers and alarms • Keep wet sponge or towel in basin on back field

33. Preparing for Fires :: • Fire Extinguishers • CO2 best choice for OR • Know location and types • Allow staff practice

34. Preparing for Fires :: Plan scenario Include safety officer Notify administration Designate observers Use drill evaluation form Select staff to participate Review policies/procedures Complete fire drill record Evaluate results

35. Preparing for Fires ::Develop Team Fire Plan Charge RN • Notify Safety Officer • Document time • Determine people in OR • Establish communication • Count casesin progress • Decide handling of patients • Assign personnel • Ask visitors to leave • Evacuate if necessary

36. Preparing for Fires ::Develop Team Fire Plan Circulating RN • Call Code Red • Remain with patient • Extinguish fire • Provide supplies • Assist anesthesia • Unplug electrical equipment • Know escape routes • Arrange patient transport • Evacuate if necessary

37. Preparing for Fires ::Develop Team Fire Plan Surgeon • Put out fire on patient • Remove burning material • Control bleeding • Conclude case if possible • Cover site with sterile towels • Assist with patient transport

38. Preparing for Fires ::Develop Team Fire Plan Scrub Person • Put out fire on patient • Remove burning material • Gather instruments/suture needed for transport • Cover with sterile towels • Assist with patient transport

39. Preparing for Fires ::Develop Team Fire Plan Anesthesia Provider • Turn off O2 and nitrous oxide • Ventilate patient • Disconnect electrical equipment • Disconnect leads/lines • Collect transport meds • Maintain anesthetic state • Assist with patient transport

40. Preparing for Fires ::Develop Team Fire Plan Ancillary Personnel • Clear all passages • Obtain transport equipment • Assist where directed

41. Preventing Fires ::

42. Control Ignition Sources :: • Electrosurgery • Use non-conductive safety holster • Use caution where GI gases / oxidizers can accumulate • Avoid metal-to-metal arcing • Activate only when tip is in view • Deactivate before tip leaves the surgical site • DO NOT activate close to sponges, surgical drapes, or flammable solutions

43. Control Ignition Sources :: • Electrosurgery • Use lowest possible power setting • Avoid long activations of ESU • Do not use ESUs to cut tracheal rings and enter airway

44. Control Ignition Sources :: • Fiberoptic Cables • Connect to scope / headlight before turning on • Turn off prior to disconnecting • Never lay illuminated or hot light cable on drapes

45. Manage Fuels :: Do not activate ignition sources in the presence of flammable agents Alcohol-based preps are involved in 4% of surgical fires

46. Manage Fuels :: • Flammable Agents • Avoid pooling of prep • Drape patient after vapors from flammable agents have dissipated

47. Minimize Oxidizers :: • Prevent accumulation of O2 and N2O under surgical drapes • Verify all breathing circuits are leak-free • Use air or < 30% O2 • Use pulse oximeter to determine O2 saturation and need for supplemental O2

48. Endotracheal Tubes :: • Use water-based lubricants • Use laser safe tubes for airway procedures • Inflate cuff with methylene blue-tinted water or saline during airway procedures

49. In Case of Fire R A C E • R – rescue the patient • A – alert the OR of the fire • C – confine the smoke and fire • E – extinguish the fire, evacuate if necessary

50. A small fire can progress to a life-threatening large fire in about 30 seconds