Nationwide review after sterilising solution fire

A national review of the use of a potentially dangerous alcohol sterilising solution is likely following an operating room fire in which a pregnant woman was badly burned.

The 17-year-old woman had skin grafts after suffering third-degree burns when her lower body was enveloped in invisible flames when a colourless, alcohol-based sterilising solution caught fire as she was having her baby delivered by caesarean.

The incident occurred at Waitakere Hospital in August.

The fire was initially hidden by a drape covering the woman and it was only when the woman complained of heat and the drape was lifted that theatre staff realised she was on fire.

Water was thrown on the fire and the baby was delivered safely.

An investigation by the Fire Service and the hospital found the sterilising solution had pooled beneath the woman when a small amount of excess solution ran down her abdomen.

Vapour collected under the drape and was ignited by an electric diathermy machine used to cauterise incisions.

The Waitemata District Health Board said it had banned the use of the alcohol-based solution from all maternity surgery and would replace it with a water-based solution.

In its report on the incident, the board said that if the alcohol solution continued to be used in other surgical specialties, it would be coloured so any excess could be easily seen.

The board said it expected every other health board in the country to carefully scrutinise the two reports on the incident and examine their own use of the solution.

"This was a very rare accident because there are so many factors which have to come together," said board spokeswoman Caroline Mackersey.

"There is a whole series of things which have to line up and that line-up very rarely occurs."

She said the ban applied only to caesareans but other specialties in the board's North Shore and Waitakere Hospitals were now reviewing their use of the alcohol solution.

The applicator used to apply the solution was introduced only two years ago but that had also been banned and operating theatre staff had reverted to forceps and gauze.

The hospital would adopt a Fire Service recommendation that where the alcohol-based solution continued to be used it would be coloured.

Changes would also be made to other handling and training processes, Ms Mackersey said.

In some specialties, the benefits of using the alcohol-based solution outweighed the risks.

- NZPA