A couple of weeks ago I read about a most distressing case of a patient who actually caught fire in an operating theatre. Fortunately the burns were not too severe – what am I saying – surely being set on fire in an operating theatre should be a ‘never-event’.
With a little reading and investigation, I find that it is not as rare a situation that I might have thought and there has been at least one death reported.
But what on earth has that got to do with a pharmacist – I hear you ask.
Just looking at the other fires they all seem to have something to do with the product used for skin preparation before surgery. I think that we all know that these alcoholic solutions must be allowed to dry before any thermal cutting tool is used. There is obviously a balance between proper technique to reduce contamination and to avoid pooling of alcoholic solution on or near the patient.
Did you know that a proportion of the fires have been caused by leaving alcohol soaked swabs near the patient. It fills me full of dread that swabs are left anywhere near a patient, but swabs soaked in alcohol are another scale of dread.
The important question is what was the preparation used – and until the report is published I don’t know the answer.
Anyway the chief pharmacist is responsible for all of the medicinal products used within the hospital. And for that matter all non-medicinal products used in a situation where a medicinal product should have been used.
Everybody has been clear on this issue – we should be using an alcoholic solution of 2% chlorhexidine unless the patient is allergic. We should be using sterile and single use preparations when available (that’s pretty obvious). And the MHRA is clear that we should be using a licenced medicinal product (also got something to do with the law defining ‘medicines’).
So where does the chief pharmacist sit if the enquiry team considers that the fire, however unfortunate, occurred when an unlicensed preparation was used, that was not sterile or single use and considered ‘not suitable for therapeutic procedures’
Actually I don’t know – so answers on a postcard please.
And before you say ‘huff – never’ – this is the most common situation in the UK.