Surgical fire case: RO health ministry investigation finds string of errors

A Health Ministry investigation into the case of the patient who died after catching fire on the operating table revealed “serious repeated errors,” health minister Victor Costache said, quoted by G4media.ro.

On December 22 of last year, a 66-year old woman caught fire during surgery when an electric scalpel was used after she was treated with an alcohol-based disinfectant. She suffered burns on 40% of her body and died one week later. The surgery took place at the Floreasca Hospital in Bucharest.

The preoperative procedure was not followed in the case, resident doctors started the intervention instead of the specialist ones who were on call, and a very large quantity of flammable disinfectant was used, something that happened in many other cases, the Health Ministry investigation found, G4media.ro reported.

The minister decided to start another investigation at the hospital after information emerged that another patient suffered burns in the operating room.

The investigation showed that Mircea Beuran, the doctor who coordinated the operating team, frequently used the highly flammable disinfectant. The biocide substance used is meant to be used only by the surgical team to disinfect their hands, not for the disinfection of the patient, the minister said.

At the same time, a procedure that stipulates that the first substance to be used for skin disinfection is betadine (Povidone-iodine) was not followed. The procedure is used nation-wide and was adopted by the Floreasca hospital in 2016. Only if the patient has an iodine allergy, should chlorhexidine gluconate be used. The patient’s iodine allergy was however misdiagnosed and no element was found to indicate it, the investigation found.

Furthermore, none of the doctors in the surgical team were on call at the time of the intervention, the investigation found. “We have a patient who bled and deteriorated over the night and an intervention was performed at 9:00 in the morning; the intervention by a resident doctor was preferred, and afterwards by a specialist who came from home instead of that of the senior doctors on call,” the minister said.

Costache also pointed to the fact that the combustion incident was mentioned in an annex of the post-surgery report, instead of being mentioned from the very beginning. Furthermore, residents should be strictly supervised by their attending doctors, which did not happen in the case, he explained.

Beuran was dismissed yesterday from his post as head of surgery at Floreasca Hospital. He was also dismissed from the post of head of Health Ministry’s General Surgery Commission. The entire operating team in the case received sanctions.