A junior doctor alone in the operating room. Large quantities of highly flammable disinfectant. A wrong diagnosis.
Health Minister Victor Costache on Tuesday presented the results of an inquiry that showed that “serious, repeated errors,” led to the case of a patient being set on fire during an operation at the Floreasca Emergency Hospital last month.
Medics used disinfectant with 89% alcohol on the woman, 66, before carrying out her operation for pancreatic cancer on 22 December. They then used an electric scalpel, which, as it came into contact with the alcohol, set the woman’s body alight on the operating table.
She suffered burns to 40% of her body and died in hospital a week later.
Costache said Tuesday that “the pre-operatory procedure was not respected, junior doctors intervened and not the specialist doctors on duty.”
“A large quantity of highly flammable substance was used, which has previously been used in dozens of other cases.”
“An ethanol substance with 89% alcohol and a major risk of combustion was used,” said Costache. “In the context that an electrical scalpel was used, this is how we ended up with this extremely serious situation.”
“None of the doctors on the operation team was working that shift,” he said. “We have a patient who was bleeding and whose condition deteriorated during the night.”
“And then instead of the operating team, they preferred a junior doctor and only then a specialist of doctor who came from home instead of the doctors who were working the shift.”
“They used 200 ml of substance, sprinkling a bit over the patient’s body and then taking a little tray and pouring it over the patient’s body.”
“It is used by the operating team to disinfect their hands, not to disinfect the patient.”
The surgeon who coordinated the operation Mircea Beuran a former health minister, “often used a highly flammable substance” as in this case, Costache said.
Beuran has been dismissed as head of the surgery department. The hospital and medics involved in the operation have been given administrative fines.
“Doctors ignored a procedure that’s been used nationally since 2016, to use betadine if the patient is allergic to iodine, as was wrongly diagnosed in this case. There’s no indication she was allergic to iodine,” he said.
He said a fifth-year junior doctor was in the operating room with a first-year junior doctor. They were later joined by a specialist doctor and two nurses.
He said an audit team was sent to the hospital where it emerged another patient suffered less serious burns on the operating table. He declined to provide details.
“I was shocked by the whole episode and the fact that a patient’s life was lost due to these basic surgical errors.”
He said the hospital would set up a commission “to establish the value of the damage and identify the people responsible.”