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Am J Med Qual. 2017 Jul/Aug;32(4):445-452. doi: 10.1177/1062860616658343. Epub 2016 Jul 11.

Flash Burns While on Home Oxygen Therapy: Tracking Trends and Identifying Areas for Improvement.

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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.
3 National Center for Patient Safety (NCPS), Ann Arbor, MI.


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.


flash burn; harm reduction; home oxygen therapy; nicotine addiction; shared decision making

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