Room Not Factor in Fatal Surgery Fire, Study Finds

Los Angeles County health investigators have determined that a flash fire that fatally burned an infant during surgery last month at Cedars-Sinai Medical Center was not linked to the fact that the operation took place in a patient care room instead of an operating room.

“There is no reason to believe that this incident would have been any different had it taken place . . . in an operating room,” said Robert Karp, program manager for health facilities at the Department of Health Services.

Nevertheless, Karp said, health officials are conducting a study to decide whether, for reasons unrelated to the fire, regulations should be adopted requiring that future surgery be performed only in approved operating rooms.

As part of their study, health investigators this week visited half a dozen major medical centers in Los Angeles to see how the surgery technique in question is handled.

Karp characterized the inquiry as a “spinoff” from the fire Oct. 6 at Cedars Sinai, in which a 15-day-old baby boy was fatally burned while doctors attempted to close a very small vessel between the baby’s pulmonary artery and the aorta. The fire is believed to have been triggered when a small pen-like instrument called a cauterizer emitted a spark that ignited a high concentration of oxygen in the room.

Hospital officials have characterized the incident as a freak event and said that that technique has been used dozens of times by the same surgical team using the same room.

Initially Health Services officials said they were surprised to learn that the surgery was not being performed in an operating room. Karp said it is unclear how explicit the Health Services Department has been in defining what sort of activity is appropriate for the room where the fire occurred.