1、慈濟綜合醫院 品管中心執行長李毅醫師Jersey General Hospital Fire18th July,1859 2005年12月15日中國遼源市中心醫院的大火造成39名住院病人死亡，事後當局將該院院長、副院長依失職罪起訴。2006年，莫斯科第17醫院發生火災，造成45名病人死亡近醫院火災94：94.01.25 埔基醫院空調機房：電線走火94.02.08 台東馬偕醫院放腫科直線加速器ups散熱(燃物品當堆放)94.12.17 高雄長庚醫院放腫科模型室：燃品當堆放95：95.05.23 高雄義大醫院美食街：電線走火95.06.09 霧峰澄清醫院管道間：配電盤95.06.29 台馬偕醫院地
2、下一：電線機房95.09.25 署台東醫院科病房：電線走火96：96.04.02中國附醫廚房：火引燃食用油97：97.03.08 中國附醫停塔：消防檢修作業失誤97.06.13 口醫院：管道間縱火97.12.17 台大醫院開刀房：電線走火98：98.1.10 馬偕醫院開刀房：電線走火98.1.11 中山附醫地下室：照明配電盤冒煙98.3.15 中國附醫心導管室：配電盤電線短98.5.3 新光吳火獅紀念醫院地下2樓資料室起火Fires in the operating roomby Yale D.Podnos,Irvine,CA,and Russell A.Williams,MD,FACS,Or
3、ange,CA the Bulletin of the American College of SurgeonsVol.82,Number 8August 1997 In the United States,there are approximately 2,260 reported hospital fires per year,resulting in about one death and 130 injuries.Of these,between 20 and 30%occur in the operating room.Historically these figures were
4、much higher.台灣病人安全通報系統台灣病人安全通報系統(TPR)(TPR)火災事件分析火災事件分析2005年至2009年6月:已收案之醫療機構公共意外事件共1,063件，其中火災有126件2008年至2009年6月 已收案之火災意外則有63件，其中5件對病人造成傷害，中度傷害1件及輕度傷害2件。原因63件火災通報事件中，77.8機構內有訂定公共意外事件應變流程(49件)，發生可能原因部分，以與器材設備相關因素為最多，共45件，又以器材設備操作不當為最多，共18件，其次為器材設備故障16件，器材設備未定期保養亦有11件。原因63件火災意外中，以電線走火17件為最多，其次為微波爐使用不當
5、15件、病人或家屬不當行為13件(在病床上抽菸、以酒精膏煮食物、隨意棄置未熄滅菸蒂)，因電器故障起火有7件，醫療人員使用器材不慎引起之火災(如滅菌鍋、熱敷帶乾燒，將加熱器材置於易燃物品上等)有4件。案例一家屬發現床頭後牆壁插座突冒黑煙並起火燃燒，立即拉鈴通知護理站，護理師立即聯絡中控室維修人員並關閉室內照明電源，並以滅火器滅火，查看後插座已燒毀，周邊牆壁燻黑，幸無人員受傷。原插座缺乏面版保護蓋，線路外露，加上線路老舊，可能因而造成走火。已加保護蓋處理，並檢查其他插座。案例二病友曾因躲在棉被中抽菸點燃床單而引發火災，經制止後已加強防範。但因菸癮大，於月日破壞消防栓取出電線，將消防栓電線接於病室插
6、孔內，進行觸電導火，成功後，燃燒紙箱及報紙製造煙霧，然後吸取煙霧來解菸癮，因煙霧漸大產生異味且逐漸蔓延，護理人員發現後，立即前往撲滅並通知主治醫師，前往處理的同仁因吸入煙霧略感不適，且病人於點火過程中亦有輕微灼傷紅腫。經主治醫師評估後，開立戒菸貼片每天使用。案例三執行手術前備妥電燒機，病人左側貼上全新電燒導電片（單極迴路版），以75酒精性優碘為病人消毒，消毒範圍由前頸至前胸乳線，並鋪無菌布單。完成後，固定手術用物：抽吸管、電燒筆，執行電燒筆測試。以75酒精紗布擦拭劃刀部位，並用乾紗布再擦拭一次。劃刀皮膚層約1.5公分，拿取電燒刀進行切割止血時，接觸病人第一時間，主刀醫師及助手驚覺溫度急速升高，
7、立刻放棄手中電燒筆，隨即發現有煙冒出，病人所戴的不織布手術帽著火，立即掀起無菌布鋪單散熱及脫下帽子，結果造成病人後頸部、雙耳廓、肩膀、背部及肩胛骨（約40*20CM）深二度灼燙傷，燙傷面積為13.5。醫策會2005年迄今收集27件與使用電刀、電燒有關之病人燒傷、產生火花點燃無菌布、紗布，甚至起火燃燒之事件。美國緊急醫療照護研究機構(Formerly the Emergency Care Research Institute；ECRI)調查發現，美國每年約有550650件手術中火災事件。Most surgical fires occur in or on the patient.The most
8、 common location of surgical fires are:During the period of April 2003 to February 2005 Tyco Healthcare Valleylab kept statistics on the number of surgical fires reported by health-care facilities.A total of 51 fires were reported:Root Causes of Fires:The Fire Triangle:Ignition Sources:Electrosurgic
9、al unitElectrocautery unitLaserSparks tissue embersIgnition Sources:Heat-producing devices High speed drill/burrs/saws Cardiac defibrillators Light sources Fiberoptic light cables Fuel Sources:In or On the PatientHair Gastrointestinal gases Gases in surgical smoke Hydrogen and methane are extremely
10、flammable gases produced by bacteria in the gastrointestinal tract in quantities of up to 200 ml per day.Forty percent of these gases are contained in the large bowel.Human flatus contains approximately 44 percent hydrogen and 30 percent methane.If in an environment of at least 5 percent oxygen,hydr
11、ogen can explode at concentrations of between 4 percent and 72 percent,while methane can explode at concentrations of between 5 percent and 15 percent.In the colon the concentration of oxygen is approximately 5 percent,but this level is increased when oxygen or nitrous oxide is administered during a
12、nesthesia.Fuel Sources:Prepping AgentsAlcohol Alcohol solutions-Up to 74%alcohol-Flammability warnings-Must dry 2-3 minutes*In ECRIs surgical fire update published February 2006,alcohol-based surgical preps were reportedly involved in 4 percent of surgical fires.Fuel Sources:Operating Room AttireBar
13、rier Materials should resist combustion Burn or melt when subjected to oxygen accelerant ALL materials burn more vigorously in the presence of oxygen Fuel Sources:SuppliesMattresses,pillows Blankets,sheets,towels Sponges,tape,ace bandages,stockinet,steridrapes Gloves Blood pressure cuffs Tourniquets
14、 Stethoscope tubing Fuel Sources:Red rubber cathetersPencil tip protectorsOther material mistakenly used as insulatorFuel Sources:Anesthesia components carry enriched oxidant gases!Breathing circuits Masks and airways Laryngeal Mask Airway Endotracheal tubes Oxidizers:OxygenOxygen-enriched atmospher
15、e=O2 above 21%Nitrous OxideThermal decomposition of N2O can supply oxygen for a fire Preparing for Fires:Locate and test gas shutoff valves and circuit breakers Evaluate traffic patterns Note location and accessibility of fire extinguishers and alarms Keep wet sponge or towel in basin on back field
16、Preparing for Fires:Fire ExtinguishersCO2 best choice for OR Know location and types Allow staff practice Preparing for Fires:Plan scenario Include safety officer Notify administration Designate observers Use drill evaluation form Select staff to participate Review policies/procedures Complete fire
17、drill record Evaluate results Preparing for Fires:Develop Team Fire PlanCharge RNNotify Safety Officer Document time Determine people in OR Establish communication Count cases in progress Decide handling of patients Assign personnel Ask visitors to leave Evacuate if necessary Preparing for Fires:Dev
18、elop Team Fire PlanCirculating RNCall Code Red Remain with patient Extinguish fire Provide supplies Assist anesthesia Unplug electrical equipment Know escape routes Arrange patient transport Evacuate if necessary Preparing for Fires:Develop Team Fire PlanSurgeonPut out fire on patient Remove burning
19、 material Control bleeding Conclude case if possible Cover site with sterile towels Assist with patient transport Preparing for Fires:Develop Team Fire PlanScrub PersonPut out fire on patient Remove burning material Gather instruments/suture needed for transport Cover with sterile towels Assist with
20、 patient transport Preparing for Fires:Develop Team Fire PlanAnesthesia ProviderTurn off O2 and nitrous oxide Ventilate patient Disconnect electrical equipment Disconnect leads/lines Collect transport meds Maintain anesthetic state Assist with patient transport Preparing for Fires:Develop Team Fire
21、PlanAncillary PersonnelClear all passages Obtain transport equipment Assist where directed Preventing Fires:Control Ignition Sources:ElectrosurgeryUse non-conductive safety holster Use caution where GI gases/oxidizers can accumulate Avoid metal-to-metal arcing Activate only when tip is in view Deact
22、ivate before tip leaves the surgical site DO NOT activate close to sponges,surgical drapes,or flammable solutions Control Ignition Sources:Electrosurgery Use lowest possible power setting Avoid long activations of ESU Do not use ESUs to cut tracheal rings and enter airway Control Ignition Sources:Fi
23、beroptic CablesConnect to scope/headlight before turning on Turn off prior to disconnecting Never lay illuminated or hot light cable on drapes Manage Fuels:Do not activate ignition sources in the presence of flammable agentsAlcohol-based preps are involved in 4%of surgical firesManage Fuels:Flammabl
24、e AgentsAvoid pooling of prep Drape patient after vapors from flammable agents have dissipated Minimize Oxidizers:Prevent accumulation of O2 and N2O under surgical drapes Verify all breathing circuits are leak-free Use air or 30%O2 Use pulse oximeter to determine O2 saturation and need for supplemen
25、tal O2 Endotracheal Tubes:Use water-based lubricants Use laser safe tubes for airway procedures Inflate cuff with methylene blue-tinted water or saline during airway procedures In Case of Fire R A C ER rescue the patientA alert the OR of the fireC confine the smoke and fireE extinguish the fire,evac
26、uate if necessaryA small fire can progress to a life-threatening large fire in about 30 seconds In the event of a small fire on the patient,immediately:Smother fire with a wet sponge or towel Remove burning material from patient For a large fire on the patient,immediately:Stop the flow of breathing
27、gases Remove burning material Care for the patient If the fire cannot be contained:Toxic smoke will form a hot,dense layer near the ceiling,obliterating overhead lights Smoke can migrate through the ventilation system and from room to room Evacuating the patientTransport the patient on OR bed Shut o
28、ff O2 and N2O valves Turn off electrical equipment,especially if water is used to douse fire If fire progresses past 1 minute,the entire OR suite should be evacuated For endotracheal tube fire,immediately and rapidly:Disconnect breathing circuit from the endotracheal tube Remove endotracheal tube Ca
29、re for patient Fire prevention is the responsibility of the entire team.ECRI於2004年針對手術使用電燒之建議注意事項含氧量超過50%將成為易燃環境，在顱顏部手術應評估是否需要使用100%氧濃度。使用含酒精性或易燃消毒液應延長乾燥時間，避免未完全乾燥的消毒液殘留在包布或是手術枱上。口咽部或使用無氣囊之氣切套管病人麻醉時可使用濕紗布置於口腔內或氣切套管周圍，減少氧氣自口咽部和肺部逸出，並可避免易燃的麻醉藥漏出。電燒或雷射手術過程中暫停使用時關閉電源，切勿將探頭置放於包布上，避免引起燃燒。各類場所消防安全設備設置標準是民國
30、78年發布，84年發生台中威爾康KTV大火後，85年即進行大篇幅修正，而建築技術規則更是多次修正。獨立空間防火區劃、室內排煙設備防火材料需有3060分鐘的防火時效防火門具有一小時以上阻熱性的功能依據TPR通報事件火災意外發生情形與可能原因檢視機構（尤其老舊建築）建築及空間規劃是否具有防火、減災功能，如空間構造、防火門功能、管道間設計防煙功能、灑水系統、警示系統等。醫療機構火災原因常與電器電路相關，應定期檢測及維修機電與各類醫療儀器設備，汰換老舊功能不良者，並注意電量負載情形。定期檢核緊急疏散路線暢通與消防、救災設備完整且功能完善。病人、家屬抽菸、隨意丟棄菸蒂，人員不當加熱食物或不當操作烘乾機、洗衣機等電器，亦可能引起火災，建議主動與病人及家屬溝通，提醒人員相關注意事項，針對吸菸病人及精神科病人尤應加強防範，以減少人為因素引發之火災意外。員工訓練建議包含火警察覺、初期滅火、限制災情(如關門)、火警通報、訊息傳遞及溝通、緊急疏散路線與病人救護、避難引導等。訂定符合機構特性的緊急災難應變計畫或防災手冊及作業程序，每年至少實際演習一次，以讓全體員工熟悉緊急應變計畫內容，並根據演習結果進行應變計畫的追蹤改善。建議對於任何手術引起的火災，醫療機構應積極的鼓勵通報，針對帶電之手術器械操作注意事項應列入標準作業流程，提醒臨床醫護人員遵行，以達到預防發生手術引起火災的可能性。Thank You
