Flash Burns While on Home Oxygen Therapy: Tracking Trends and Identifying Areas for Improvement. (July 2017)

• Record Type: Journal Article
• Authors: Wolff, Kristina B.; Soncrant, Christina; Mills, Peter D.; Hemphill, Robin R.
• Is Part Of: American journal of medical quality. Volume 32:Number 4(2017:Jul./Aug.)
• Page Start: 445
• Page End: 452
• Publication Date: 2017-07
• Subjects: nicotine addiction -- harm reduction -- shared decision making -- home oxygen therapy -- flash burn; Medical care -- Quality control -- Periodicals; Medical care -- Evaluation -- Periodicals; Medical care -- Utilization review -- Periodicals; Medical care -- United States -- Periodicals; 362.1
• DOI: 10.1177/1062860616658343
• Languages: English
• ISSNs: 1062-8606

Abstract

The objective was to analyze reported flash burns experienced by patients on home oxygen therapy (HOT) in the Veterans Health Administration (VHA) using a qualitative, retrospective review of VHA root cause analysis reports between January 2009 and November 2015. Of 123 cases of reported adverse events related to flash burns, 100 cases (81%) resulted in injury, and 23 (19%) resulted in death. Although 89% of veterans claimed to have quit smoking (n = 109), 92% (n = 113) of burns occurred as a result of smoking. The most common root cause was risk identification issues. Recommended actions were standardized risk assessment policies, patient education, and the adoption of fire stop valves. Patients with a history of smoking who are on HOT should be considered for fire stop valves and offered consistent counseling and follow-up using a combination of harm reduction and shared decision-making techniques. Standardization of risk identification and documentation is recommended.