Oxygen-Enriched Environments Increase the Fire Risk from Alcohol-Based Hand Sanitizers

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Oxygen–Enriched Environments Increase the Fire Risk from Alcohol-Based Hand Sanitizers

PA PSRS Patient Saf Advis 2006 Dec;3(4):11.

Ignition of alcohol-based hand sanitizers in oxygen-enriched environments in healthcare facilities can lead to serious fires, according to a hazard report published in the October 2006 issue of ECRI’s Health Devices.

The hazard report discussed a reported event in which a nurse in a neonatal intensive care unit was rubbing sanitizer into her hands as she approached an oxygen/air proportioner to change a setting. An investigation into the event concluded that the nurse’s movements created a static electric charge that discharged to the grounded proportioner when she reached for the device’s control knob.

Because the three requisite components of a fire were in place—an ignition source (i.e., the electrostatic discharge), a fuel (i.e., the hand sanitizer), and oxygen (i.e., present in the room air and in the oxygen-enriched environment surrounding the proportioner)—a fire ignited the sanitizer on the nurse’s hand and on the control knob. The nurse’s hand was burned; however, nearby clinicians were able to disconnect the device and extinguish the flames before additional injuries occurred or the fire spread. In the presence of normal oxygen concentration in the room air, the electrostatic discharge may have only ignited the sanitizer on the nurse’s hand, but because of the oxygen-enriched environment surrounding the control knob, the knob also caught fire.

Suggestions from the hazard report for users of alcohol-based hand sanitizer include the following:

Alerting users to this potential problem.
Directing users to ensure that sanitizer fully evaporates from their hands before they touch devices, bed linens, or patients.

Source: ECRI. Fire risk from alcohol-based hand sanitizers worsens in oxygen-enriched environments. Health Devices 2006 Oct;35(10):390.

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Oxygen-Enriched Environments Increase the Fire Risk from Alcohol-Based Hand Sanitizers
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	THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS
	The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web site at www.patientsafetyauthority.org .
	ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.
	The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.