By Nasrin Mirsaidi, RN, CNOR, MSN
(Article reprinted from August Nursing2008, Volume 38, Number 8, Pages 13-14)
AFTER A PATIENT had a wound debridement procedure in the OR with a disposable battery-operated lavage system (BOLS), she was transferred to the postanesthesia care unit. Then a staff member in the OR separated the battery pack from the device by cutting its cable. She put the battery pack on a cart and disposed of the rest of the device. A short time later, the battery pack exploded, spreading ashlike substances throughout the OR. Because the OR was empty at the time of the explosion, no one was injured.
The FDA has also received reportsof sparks and smoke occurring after battery pack cables were cut.
What went wrong?
Powered by 8 to 10 AA alkaline batteries, a BOLS provides pulsed irrigation to remove necrotic or infected tissue and debris from wounds with pressurized irrigating solution. It can be used in the OR, ED, burn unit, or nursing unit.
In this case, cutting the battery pack’s cable caused a short circuit. The batteries discharged rapidly and produced intense heat and flammable gases. Pressure that built up inside the battery pack resulted in an explosion. Battery explosions expel flammable gases and toxic chemicals. Even though no serious injury or damage resulted from this event, patients and staff are at risk any time sparks, arcs, and explosions occur.
The FDA investigated the event and identified two reasons why staff cut the cable to separate the battery pack:
- Staff members are told to dispose of batteries in hazardous waste instead of with regular trash.
- Staff members take batteries home for personal use because very little battery energy is used up during procedures.
What precautions can you take?
To avoid the risk of sparks, fires, toxic fumes, and explosions:
- Read the device manufacturer’s labeling, paying particular attention to warnings. Manufacturers generally warn users not to cut the battery pack’s cable to avoid electric shock, sparks, fire, or explosion. Some manufacturers put only one labeling booklet in a box with several BOLS devices, so make sure a copy of the labeling is placed with each device.
- Don’t remove used batteries or other used items from any patient-care setting for personal use. This practice is
inconsistent with infection control guidelines.
- Follow your facility’s policy for disposing of batteries in accordance with appropriate state and local regulations.
Most states don’t require alkaline batteries to be discarded with hazardous material.
- If a battery pack explodes, notify your facility’s hazardous materials response team as soon as possible. Make
sure the fumes and decomposition products don’t contact anyone’s eyes or skin and vapors aren’t inhaled.
- If battery materials contact someone’s eyes, flush them with large amounts of tepid water for 30 minutes. Contact a physician at once.
- If a battery leaks on a person’s skin, irrigate the exposed area with large amounts of tepid water for at least 15 minutes. Contact a physician if irritation, pain, or injury persists.
- If someone inhales vapors from a leaking battery, his respiratory passages may be irritated. Take him to an area with fresh air. Contact a physician if irritation continues.1
Taking these precautions can prevent patient and staff injuries.
Although you need to support your health care facility’s adverse event—reporting policy, you may voluntarily report a medical device that doesn’t perform as intended by contacting MedWatch at 1-800-FDA-1088 (fax: 1-800-FDA-0178) or online at MedWatch.