Mr P was a 32-year-old runner. He had a skin tag on his back that kept catching on his clothes when he ran. It had become quite sore on a few occasions and he was keen to have it removed. He saw his GP, Dr N, who offered to remove the skin tag in one of his minor surgery sessions.

The following week, Mr P attended the minor-surgery clinic at his GP practice. Dr N explained that he was going to use diathermy to remove the skin tag and Mr P signed a consent form.

Mr P lay on the couch and a sterile paper sheet was tucked under him. The assisting nurse sprayed his skin with Cryogesic, a topical cryo-analgesic. The spray pooled on his back and soaked into the paper sheet. No time was left for the alcohol-based spray to evaporate. Mr P’s back was still wet when Dr N began the diathermy to remove the skin tag. Unfortunately, the paper sheet caught fire along with the pooled spray on his back. Mr P suffered a superficial burn. Dr N and the nurse apologised immediately and applied wet towels and an ice pack. The burn area was treated with Flamazine cream and dressings. Mr P was left with a burn the size of a palm on his back which took two months to heal fully.

Mr P made a claim against Dr N, alleging that his painful burn had been the result of medical negligence. It is well known that alcoholbased solutions pose a risk of fire when diathermy is used, and in failing to ensure the area was dry before applying the diathermy Dr N was clearly in breach of his duty of care. Medical Protection was able to settle the claim quickly, thus avoiding unnecessary escalation of legal costs. 

Learning Points

• Flammable fluids employed for skin preparation must be used with caution. GP practices should refer to safety data sheets before using these products. The data sheet for Cryogesic states that it “may form a flammable/explosive vapour–air mixture ” and that one should “ensure good ventilation and avoid any kind of ignition source”.1
• The Medicines and Healthcare products Regulatory Agency (MHRA) warns that “spirit-based skin preparation fluid should not be allowed to pool and should be dry or dried before electrosurgery commences”.2
• The fire triangle is a simple model illustrating the three necessary ingredients for most fires to ignite: heat, fuel, and oxygen. In clinical situations such as the one described above, diathermy provides the heat and skin preparation fluids provide the fuel.3
• According to the the National Patient Safety Agency (NPSA), when a medical error occurs it is important to document the incident as soon as possible after it has happened. This should include the date, time and location of events. It also advises that it is best practice to apologise because openness and honesty can help to prevent formal complaints and litigation. Doctors should also report incidents via local reporting systems to help improve patient safety and to discuss adverse incidents with colleagues to learn lessons and create solutions to improve future care.4

References

• Cryogesic Safety Data Sheet
•  Medicines and Healthcare Products Regulatory Agency, SN 2000(17)–Use of Spirit-based Solutions During Surgical Procedures Requiring the use of Electrosurgical Equipment, London: MHRA (2000)
• Rocos B and Donaldson L, Alcohol Skin Preparation Causes Surgical Fires, Ann R Coll Surg Engl 94(2):87–9 (2012)
• National Patient Safety Agency, Medical Error