title: Flash Burns While on Home Oxygen Therapy: Tracking Trends and Identifying Areas for Improvement.
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.
authors.affiliation: 1 VA National Center for Patient Safety Field Office (NCPS), White River Junction, VT.
authors.forename: Kristina B
authors.initials: KB
authors.lastname: Wolff
authors.affiliation: 1 VA National Center for Patient Safety Field Office (NCPS), White River Junction, VT.
authors.forename: Christina
authors.initials: C
authors.lastname: Soncrant
authors.affiliation: 1 VA National Center for Patient Safety Field Office (NCPS), White River Junction, VT.|2 The Geisel School of Medicine at Dartmouth College, Hanover, NH.
authors.forename: Peter D
authors.initials: PD
authors.lastname: Mills
authors.affiliation: 3 National Center for Patient Safety (NCPS), Ann Arbor, MI.
authors.forename: Robin R
authors.initials: RR
authors.lastname: Hemphill
mesh_terms: D000368:Aged; D002056:Burns / Q000209:etiology*; D004867:Equipment Design; D006699:Home Care Services / Q000592:standards* / Q000706:statistics & numerical data*; D006801:Humans; D008875:Middle Aged; D010102:Oxygen Inhalation Therapy / Q000009:adverse effects*; D010353:Patient Education as Topic / Q000458:organization & administration; D061214:Patient Safety; D012189:Retrospective Studies; D018570:Risk Assessment; D060891:Root Cause Analysis; D012907:Smoking / Q000453:epidemiology; D014481:United States; D014493:United States Department of Veterans Affairs
keywords: flash burn; harm reduction; home oxygen therapy; nicotine addiction; shared decision making