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Cutting a Battery Pack Cable Can Start a FireBy Nasrin Mirsaidi, RN, CNOR, MSN(Article reprinted from August Nursing2008, Volume 38, Number 8, Pages 13-14) AFTER A PATIENT had a wound debridement procedure in the OR with a disposable battery-operated lavage system (BOLS), she was transferred to the postanesthesia care unit. Then a staff member in the OR separated the battery pack from the device by cutting its cable. She put the battery pack on a cart and disposed of the rest of the device. A short time later, the battery pack exploded, spreading ashlike substances throughout the OR. Because the OR was empty at the time of the explosion, no one was injured. The FDA has also received reportsof sparks and smoke occurring after battery pack cables were cut. What went wrong?Powered by 8 to 10 AA alkaline batteries, a BOLS provides pulsed irrigation to remove necrotic or infected tissue and debris from wounds with pressurized irrigating solution. It can be used in the OR, ED, burn unit, or nursing unit. In this case, cutting the battery pack’s cable caused a short circuit. The batteries discharged rapidly and produced intense heat and flammable gases. Pressure that built up inside the battery pack resulted in an explosion. Battery explosions expel flammable gases and toxic chemicals. Even though no serious injury or damage resulted from this event, patients and staff are at risk any time sparks, arcs, and explosions occur. The FDA investigated the event and identified two reasons why staff cut the cable to separate the battery pack:
What precautions can you take?To avoid the risk of sparks, fires, toxic fumes, and explosions:
Taking these precautions can prevent patient and staff injuries. REFERENCES Although you need to support your health care facility’s adverse event—reporting policy, you may voluntarily report a medical device that doesn’t perform as intended by contacting MedWatch at 1-800-FDA-1088 (fax: 1-800-FDA-0178) or online at http://www.fda.gov/medwatch/how.htm. The opinions and statements in this report are those of the author and may not reflect the views of the Department of Health and Human Services. Beverly Albrecht Gallauresi, RN, BS, MPH, who coordinates Device Safety, is a cardiovascular nurse-consultant at the Center for Devices and Radiological Health at the Food and Drug Administration in Rockville, Md. Nasrin Mirsaidi is a nurse-consultant for general and plastic surgery devices at the Center for Devices and Radiological Health. Updated September 4, 2008 |
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