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Safety Hazard with Disposable Battery-Operated Lavage System

Filed September 9th, 2008 laurie

The FDA on its website today reprinted an article from August Nursing2008 highlighting safety hazards that can result from cutting the battery pack cable on a disposable lavage system.

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 reports of sparks and smoke occurring after battery pack cables were cut.

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.

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