The Joint Commission Issues Quick Safety Advisory on Preventing Light Source-Related Burns During Surgical Procedures

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Katie Bronk
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(OAKBROOK TERRACE, Illinois, April 11, 2023) – Laparoscopic or arthroscopic procedures have the potential to cause patient burns from the light sources associated with these scopes. Burns from these types of light sources can go unnoticed because they typically do not produce smoke or charring, even of surgical drapes.

Since 2019, more than half of fire/burn sentinel events voluntarily reported to The Joint Commission were associated with surgical or invasive procedures, and nearly 15% of those peri-procedural incidents were related to light sources. A new Quick Safety advisory from The Joint Commission, “Preventing light source-related burns from laparoscopy and arthroscopy,” details how light sources can cause burns and provides recommended safety actions and resources.

Laparoscopic and arthroscopic surgery requires a complex illumination system to provide adequate visualization of an enclosed body cavity or bone joint. Instrument or component malfunction can lead to excessive heat generation and result in patient burns. There are two major components to the illumination system: the light source and the light cable.¹ Both components have the capability to generate high and hazardous temperatures.

Safety actions outlined in the advisory include:

• Educate all surgeons, including physicians in-training, who perform laparoscopic or arthroscopic procedures on the importance of handling scopes safely.¹
• Implement system changes to minimize the risk of patient burns associated with laparoscopy and arthroscopy.¹
• Label light sources with the following: “Warning: High-intensity light sources and cables can ignite drapes and other materials. Complete all cable connections before activating the light source.”¹
• Do not turn on the light source before the cable is connected to the scope; the end of the cable becomes hot and could ignite dry combustibles.¹
• If the cable is disconnected from the scope during surgery, hold the cable end away from the drapes or place it on a moist towel.¹
• Keep illuminated light cords away from drapes, patient’s skin, personnel’s skin and any flammable material.¹
• Connect the correct size light source to the correct scope.
• Inspect all instruments and equipment before use to ensure the equipment is in good working order.¹

“As a surgeon, I know that surgical burns have a devastating effect not only on the patient, but also on the surgical team members taking care of that patient,” says Haytham Kaafarani, MD, MPH, FACS, chief patient safety officer and medical director, The Joint Commission. “It is important that hospitals and ambulatory surgery centers take system-level safety actions to prevent this type of sentinel event from occurring – especially since surgical burns can occur within a matter of seconds and without the knowledge of the surgical team. When the entire surgical team is aware of the causes of surgical burns and follows preventive measures, we can help reduce harm to patients.”

The full Quick Safety advisory is available on The Joint Commission website. It may be reproduced if credited to The Joint Commission.

¹Ball K. Lap Burn. Agency for Healthcare Research and Quality, PS Net. Oct. 1, 2004.

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About The Joint Commission

Founded in 1951, The Joint Commission seeks to continuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission accredits and certifies more than 22,000 healthcare organizations and programs in the United States. An independent, nonprofit organization, The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in healthcare. Learn more about The Joint Commission at www.jointcommission.org.