658343

research-article2016
AJMXXX10.1177/1062860616658343American Journal of Medical QualityWolff et al

Article
American Journal of Medical Quality

Flash Burns While on Home

18
The Author(s) 2016
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DOI: 10.1177/1062860616658343

and Identifying Areas for Improvement ajmq.sagepub.com

Kristina B. Wolff, PhD, MS, MPA, MPH1, Christina Soncrant, MPH1,

Peter D. Mills, PhD, MS1,2, and Robin R. Hemphill, MD, MPH3

Abstract
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.

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

Approximately 1.4 million people in the United States are
on long-term oxygen therapy.1,2 Home oxygen therapy
(HOT) has been shown to successfully treat hypoxemia
related to chronic obstructive pulmonary disease (COPD),
improving patients quality of life and morbidity.1 COPD
may be caused by chemical fumes or dust; the most com-
mon cause of COPD is smoking.3,4 Treatment for COPD
often consists of a combination of home oxygen and
smoking cessation therapies. It is estimated that $1.7 bil-
lion is spent on health care treating smoking-related ill-
nesses, with $983 million spent yearly on Veterans Health
Administration (VHA) patients. HOT is safe if individu-
als avoid using oxygen when near sources of spark or
flame such as candles, pilot lights, and smoking materi-
als. On rare occasions, individuals may experience flash
burns if near open flames or sparks, which will result in
injury, death, or destruction of property.3-8 This article
examines reports of injuries and deaths from flash burns
experienced by VHA patients from January 2009 to
November 2015.
In 2005 close to 21% of people in the United States
smoked tobacco; by 2013, the percentage dropped to
17.8%.9 The income, educational level, race or ethnicity,
and sex of an individual influence tobacco use.9-12 The
higher a persons education level, the less likely they are
to smoke; smoking decreases as people get older.9-12
Native Americans/Alaska Natives have the highest
reported percentage of smokers (29%) and Asian/Pacific
Islanders the lowest (9%).9 Current estimates are that
close to 19% of men and 15% of women in the United
States smoke tobacco.9 These proportions differ in the US
military; estimates range between 30% and 33% of ser-
vice members, and 20% to 52% of veterans use
tobacco.13-15 Women who served since the beginning of
the conflicts in Afghanistan and Iraq are reportedly smok-
ing at higher rates than men.13
Historically, smoking has been an acceptable part of
military culture.16,17 Use of tobacco is higher in indi-
viduals with combat and other types of trauma experi-
ences and in people with substance use disorder or
mental health conditions, including post-traumatic
stress disorder.11,13,18,19 In addition to increased risk of
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
Corresponding Author:
Kristina B. Wolff, PhD, MS, MPA, MPH, Dartmouth CollegeMasters
of Health Care Delivery Science Program, 37 Dewey Field Rd,
Hanover, NH 03755-3529.
Email: Kristina.B.Wolff@dartmouth.edu

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2 American Journal of Medical Quality
COPD, smokers are at higher risk for lung cancer,
stroke, and coronary heart disease as well as increased
use of health care and overall diminished health.9,10 It is
estimated that from 1997 to 2001, smoking tobacco
caused 438000 premature deaths.9,10
Nicotine addiction is considered to be one of the more
difficult addictions to overcome and is the most common
form of addiction in the United States.9,10 Individuals
who successfully quit smoking without some form of
smoking cessation are usually younger than age 40.
Smoking cessation efforts include nicotine replacement
therapy (NRT; nicotine gum or patch) with or without
some form of behavioral therapy.1,15,20-23 Varencline and
bupropion combined with NRT have been shown to
assist in prolonging smoking abstinence, but few studies
show how well these work with elderly individuals.23
Research shows that individuals need at least 5 weeks of
psychotherapy and seniors (>64 years old) require recur-
rent counseling to successfully abstain from tobacco
use.18,22,24 It should be noted that although it is safe, NRT
may not effectively assist users to remain abstinent after
24 weeks.20,22,25-28
Sex and other social determinants can affect a patients
success at abstaining from nicotine use.11,12,20,29,30 For
example, a harm reduction approach that includes moti-
vational interviewing and takes a trauma-informed
approach is more effective for women.11,12,31 Harm
reduction approaches treat addiction as a chronic illness
rather than as a secondary condition to illness.10,11,15,21,32
These methodologies encourage shared decision making,
which can improve trust and patient autonomy in rela-
tionship to their health and wellness. Together, patient
and provider are active partners in determining care plans
to reduce the use of nicotine.21,26,31,32
It is difficult to determine how many individuals on
HOT continue to smoke. Estimates range from 10% to
50%.1,4,8 Although rare, sparks and open flames can cause
flash burns that injure or cause the death of patients and
others around them as well as damage to property.4,7,13,31,33,34
Reporting of these events is spotty at best and often reliant
on people who know the patient rather than the patient
reporting the injury. Sharma etal1 estimate the absolute
risk of burn injury in patients on home oxygen therapy as
2.98 per 1000 patients compared with 1.69 per 1000 for
patients not prescribed oxygen.1(p495) The severity of the
burn is often related to how quickly the flames can be
extinguished and oxygen turned off. Many elderly indi-
viduals who experience these burns often require longer
hospitalization.6,34 Although smoking continues to decline,
10% of fire-related deaths worldwide are from
smoking.7,8,34 The aim of this project was to examine root
cause analysis (RCA) reports of injuries and deaths from
flash burns experienced by VHA patients on HOT. The
goal was to identify and report commonalities in stated
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root causes and actions taken to improve care and reduce
harm to patients and to provide recommendations based on
these actions.
Methods
Study Design
This is a qualitative, retrospective study of RCA reports
involving patient burns while on HOT that occurred
within the VHA between January 2009 and November
2015. This included patients on HOT who sustained
burns at home, in public, in hospitals, and in other clini-
cal settings. The Committee for the Protection of
Human Subjects, Dartmouth College, considered this
project exempt from further institutional review.
SQUIRE 2.0 was used as the framework in preparation
for this article.
The Veterans Affairs (VA) National Center for
Patient Safety RCA Program
The VHA system provides health care services to veter-
ans across the United States through 152 VA Medical
Centers, community living centers, and home-based pri-
mary care. The National Center for Patient Safety (NCPS)
investigates patient safety issues, including examinations
of adverse events that occur throughout the health care
system to improve system-wide issues and the delivery of
care.35 The NCPS has instituted an RCA program to indi-
vidually and collectively analyze adverse events.
RCA is a method for examining the underlying causes
of adverse events. The focus of an RCA is on the systemic
and organizational factors that may have contributed to
an adverse event, including environmental factors, break-
downs in communication of critical information from one
clinician to another, nonstandardized processes for
assessing or treating patients, training, and fatigue.35 This
system includes a computer-aided tool and a flip-book
containing a series of 6 triage questions to help teams
identify where the system can be improved. To determine
whether an adverse event should be reviewed using the
RCA process, each event is coded according to severity
of the incident (minor, moderate, major, catastrophic) and
its probability of occurrence (remote, uncommon, occa-
sional, frequent), called the Safety Assessment Code.3
Events with high severity and/or probability of recurring
are reviewed using the RCA process.
Next, a multidisciplinary team is chartered to estab-
lish the sequence of events leading to the adverse event,
conduct fact finding, and synthesize the information
acquired using the tools and resources available. The
RCA team is composed of clinicians and administrators
who are knowledgeable about the systems and process
Wolff et al 3
under review in the area but are not directly involved in
the case. Once a final sequence of events is determined,
the team identifies root causes and contributing factors.
Action plans are then developed to address these root
causes and a measurement system put in place to moni-
tor the implementation and effectiveness of the actions.
In general, an RCA describes what happened, how it
happened, and what should be done to avoid the same
event happening again. The focus is on systemic
changes that can be made at the unit, clinic, or facility
level to reduce the chances of the same type of event
happening again.
Because of the focus on the system, the information
contained in the RCA reports has limited demographic or
epidemiological data about the patients involved in the
events. In contrast, RCA reports contain detailed infor-
mation regarding the event, the underlying systemic
causes of the event, and potential actions to prevent reoc-
currence. The RCA reports are submitted to NCPS via a
secure electronic reporting system within 45 days of the
adverse event. Once in the national database, each RCA
report is coded using the Primary Analysis Categorization
system. This system assigns codes for location, event
type, activities, or processes closely associated with the
event; actions taken; and outcome measures used. In
addition, actions are coded for strength of effectiveness,
whereas permanent changes or standardization of a pro-
cess are coded as stronger than attempts to change staff
behaviors through education or policy changes. Once
coded, the full RCA reports and codes are available for
review by NCPS staff.
Analysis of RCA Reports
RCA reports from January 2009 to November 2015 (n =
8237) were analyzed, using conventional content analysis
methods, for adverse events related to HOT. RCA reports
were searched for specific words and phrases using the
Find function in Excel (Microsoft Corp, Redmond,
Washington) and a thorough reading of the RCA reports.
The search included the following terms that appear in
the RCA text: smoking/smoke, fire, burn, oxygen/home
oxygen, cannula, cigarette, flame, died/deceased, injured/
injury, and spark. RCA reports of close calls and safety
reports that did not have an RCA were excluded, leaving
a final study data set of cases that led to actual patient
harm. Once duplicate cases and cases unrelated to flash
burns on HOT were eliminated, the remaining cases (n =
123) were organized by year of incident and divided into
injured and deceased patients.
Codebooks were developed inductively for patient and
incident characteristics, root causes, and actions as deter-
mined in the RCAs. Two coders independently coded
10% of root causes and 15% of the actions until more
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than 85% concurrence was reached (coefficient was
0.81). The remaining cases were coded separately; cases
or root causes that did not clearly fit into one category
were coded by consensus. Subcategories also were devel-
oped to further analyze and illustrate the variation within
reported root causes and actions.
Results
Characteristics of the sample are presented in Table 1. Of
the 123 veterans experiencing flash burns on HOT, almost
19% died from injuries related to the burn. Most of the
deaths and injuries happened at home. Although almost
90% of veterans claimed to have quit smoking, more than
90% of flash burns started because of smoking. Substance
use disorder was noted in almost one quarter of the
patients; many (37%) had multiple comorbidities, but
only 5% (6) of the incidents mentioned comorbidities as
a factor in the patients flash burn. All but 2 veterans were
male (Table 1).
The RCA data revealed 2 common inconsistencies in
caring for HOT patients. RCA reports frequently noted
lack of information regarding veteran participation in
smoking cessation programs or missing risk identifica-
tion for smoking while on HOT. Almost half of the RCAs
stated that there was no information regarding smoking
cessation involvement compared with the 29% of patients
who were offered smoking cessation. The number of
patients who were offered smoking cessation and refused
to participate and the number who were not offered smok-
ing cessation are shown in Table 1.
Veteran risk of smoking while on HOT was noted
before the incident in more than one quarter of the RCAs
(Table 1). In close to one third of cases, high risk for
smoking was known but not reported in the patients
health record, compared with 15% where risk was deter-
mined and documented after the flash burn happened.
The remaining cases had no recognized risk status (Table
1). A small percentage of veterans used some form of fire
stop device; 78% (7) of these devices were used between
2013 and 2015. Only one of the deceased patients had
been issued a fire stop valve.
There were 240 root causes identified in the cases;
these were organized into 16 distinct categories (Figure 1).
The most common root cause was risk identification,
and the least common were substance use disorder and
no root cause. Combined, patient noncompliance, patient
education, and policy change or standardization of pol-
icy represent 54% of all root causes (Figure 1). One of
the challenges with tackling rare adverse events is iden-
tifying commonalities between incidents that can be
addressed as a means to reduce these events. To address
this, subcategories were organized to show the distribu-
tion of them within the root causes from the RCA cases.
4 American Journal of Medical Quality

Table 1. Reported Characteristics of the Sample (n = 123).

Injury, n (%) Death, n (%)

Total number of patients 100 (81.3) 23 (18.7)
Average age (if known) 66.5 66.3
Most common comorbidities noted
Pulmonary (eg, chronic obstructive pulmonary disease, dyspnea) 32 (32.0) 14 (60.9)
Mental health 27 (27.0) 5 (21.7)
Cardiovascular (eg, hypertension, coronary artery disease) 21 (21.0) 2 (8.7)
Cognitive function (eg, dementia, forgetfulness) 13 (13.0) 3 (13.0)
Substance use disorder (in addition to tobacco) noted 21 (21.0) 9 (39.1)
Patients with a substance use disorder and mental health conditions 8 (8.0) 3 (13.0)
Patients who claimed to have quit smoking 87 (87.0) 22 (95.6)
Determination of patient risk for smoking on home oxygen therapy noted
High risk 23 (23.0) 2 (8.7)
Low risk 6 (6.0) 2 (8.7)
Risk known, documented after incident 30 (30.0) 9 (39.1)
Risk determined after incident 19 (19.0) 0
No risk information noted 22 (22.0) 10 (43.5)
Ethics consultation conducted 10 (11.5) 0
Patient issued fire safety valve 7 (7.0) 2 (8.7)
Smoking cessation noted
Offered 27 (27.0) 9 (39.1)
Refused 14 (14.0) 5 (21.7)
Not offered 18 (18.0) 1 (4.3)
Unknown 41 (41.0) 8 (34.8)
Patient was alone when flash burn occurred 55 (55.0) 10 (43.5)
Incident location
Home 74 (74.0) 22 (95.6)
VAMC or VA community living center
Patients room 10 (10.0) 1 (0.4)
Designated smoking area (ie, smoke shack) 11 (11.0) 0
Outside 5 (5.0) 0
Waiting room 1 (1.0) 0
Cause of flash burn
Smoking 90 (90.0) 23 (100)
Open flame (candle, welding, pilot light) 5 (5.0) 0
Electric heater 1 (1.0) 0
Unknown 4 (4.0) 0

Abbreviations: VA, Veterans Affairs; VAMC, Veterans Affairs Medical Center.

For example, of all cases identifying policies as a root
cause, communication issues of policies and risk identi-
fication procedures were noted as a policy concern in
more than 15% of the cases compared with smoking ces-
sation policies, which were recognized in less than 5% of
the cases.
Actions are shaped by the culture and resources of
the VHA facility and its veteran patient population; this
is evident in the variety of recommended actions listed
in the cases examined. In all, 388 actions were recom-
mended for the 123 RCA cases (Figure 2). The most
common actions discussed were improved documenta-
tion; improved follow-up for patients; improvement of
patient, family, and staff education; and improved
communication.
Discussion
Although a relatively rare type of adverse event, flash
burns during HOT use can result in catastrophic injuries
or death of the patient as well as others in the same loca-
tion. In the RCA reports that were examined, missing or
inaccurate information regarding risk identification for
smoking was the most frequently noted root cause (16%,
n = 38). Consequently, it is recommended that facilities
standardize the process of identifying and documenting

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Wolff et al 5

Figure 1. RCA root causes (240), by number and percentage.

Abbreviation: RCA, root cause analysis.

Figure 2. Recommended action categories (388), by number and percentage.

patient risk of smoking. Facilities also should consider
creating levels of risk classification (high, medium, low)
for both inpatient and outpatient (HOT) care that are
based on patient age, lifetime smoking history, and
comorbidities, including mental health status, substance
use, and chronic illness, because this combination appears
to influence patient smoking on HOT.4,10-13,30,36,37
The majority (92%, n = 113) of flash burns and fires
occurred while the patient was smoking. Slightly more
than half (53%, n = 65) of the patients were alone when
the flash burn occurred. The patients ability to put out
a fire quickly may be one of the common factors in
determining the level of harm experienced by the
patient.4,6 There was a marked increase in the use of fire
stop valves for cannulas from 2013 to 2015, with 78%
(n = 7) of valves being issued during this time period.
Eleven (3%) RCAs recommended requiring fire stop
valves for patients with a smoking history; 64% (n = 7)
of these recommendations occurred between 2013 and
2015.5 Standardizing the use of equipment that reduces
the likelihood of human error provides extra time to
stop the fire as oxygen is stopped. It is a strong action
because it is less dependent on changing behaviors,
which is particularly challenging when the behavior is

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6 American Journal of Medical Quality
tied to addiction.31,38,39 Adoption of these devices is
cost-effective, will aid in stopping fires more quickly,
and serves as a good complement to shared decision
making.32 The study team recommends that patients
with any history of smoking and on HOT be considered
for fire stop valves.
Lack of participation in smoking cessation programs
as well as lack of compliance regarding not smoking on
HOT also were common root causes. Current VHA pol-
icy requires NRT as part of a cessation program and
immediate abstinence from smoking.15 Compliance is
complicated by the strength of nicotine addiction
because many veterans on HOT have been smoking for
decades.6,8,28,30,39 A couple of RCAs noted exploring the
use of vape pens and e-cigarettes as alternatives to
smoking cigarettes. These products do not have Food
and Drug Administration approval, and there are reports
of health hazards related to these items; therefore, the
study team does not recommend their use. Because NRT
may not be effective over a long period of time and
older individuals often need consistent counseling, the
study team recommends expanding the current smoking
cessation efforts to adopt a harm reduction approach
combined with the use of fire stop valves and a shared
decision-making approach.
A few patients claimed that they had not smoked in
years when they decided to have a cigarette and experi-
enced a flash burn; this was supported by some of the
RCA reports. Because of the nature of tobacco addiction,
it is not unusual that patients who experience long periods
of abstinence start smoking again.37,39 Although difficult
to quantify, an underlying sense of patient hesitancy to
report smoking because of the potential loss of HOT
emerged while examining the RCAs. This could be
related to the tension discussed in cases (8%, n = 10) that
went to an Ethics Consultation for review. In each of
these cases, the committee considered stopping HOT, yet
decided in favor of the patients personal autonomy and
allowed the HOT to continue. Many providers may note
that losing HOT is possible if one smokes; therefore, the
combination of fear of losing ones HOT, fragmented
follow-up of care, and cessation programs based on absti-
nence may have contributed to patients denial of smok-
ing while on HOT in many of the RCAs examined. Some
of the actions addressing uncertainty around losing HOT
focused on improving follow-up and coordination of care
for HOT patients. Adopting the combination of harm
reduction with a shared decision-making approach to care
would improve care coordination, communication, and
patient outcomes because it encourages a team approach.
Although challenging to adopt, a shared decision-making
approach builds trust between patient, provider, and care
team. As these relationships improve, it is possible that
patients will be more open regarding their smoking.
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Limitations
This study has several limitations and biases of note.
The data for this study are composed solely of adverse
events that were reported to the NCPS through the RCA
system. The majority of these events occurred in the
home; therefore, these events were reported as a result
of patient self-report to providers, family reporting
events to providers, or the facilities finding out about a
flash burn through other means. Many patients did not
report smoking while on HOT, which can be attributed
to stress and focus on other health issues, length of time
of nicotine addiction, other life stressors, or mistrust of
providers.4,28,37,39 Because of the nature of reporting,
this data set does not include every adverse event related
to flash burns while on HOT, and therefore, these data
serve as a snapshot of what may be occurring within the
veteran population on HOT.
This is a descriptive study based on qualitative data
of rare events. Through analyzing the RCAs in aggre-
gate, it is possible to identify overarching themes and
common contributing factors and provide suggestions
for preventing future events. By definition, the adverse
events requiring an RCA include cases that lead to
serious actual or potential harm to the patient. This
study included only those cases that resulted in actual
harm. Therefore, the data set resulted in a strong selec-
tion bias toward high-harm adverse events. Finally,
because RCA reports focus on systems issues, the
information in the data set does not contain demo-
graphic data about patients or staff involved in these
events. Finally, the data are from patients in the VHA
system, and the results may not generalize easily to
other civilian populations.
Conclusion
These limitations notwithstanding, the study team makes
the following recommendations for improving care for
patients on HOT: Facilities should standardize the pro-
cess of identifying and documenting patient risk of smok-
ing. Serious consideration should be given to the creation
of levels of risk classification (high, medium, low) for
both inpatient and outpatient (HOT) care. The study team
recommends that patient age, lifetime smoking history,
and comorbidities, including mental health status and
substance use, be included when creating these different
levels. Because NRT may not be effective over a long
period of time and older individuals need consistent
counseling, the team recommends expanding the current
smoking cessation efforts to adopt a harm reduction
approach combined with shared decision-making tech-
niques. Finally, patients with a history of smoking who
are on HOT should be considered for fire stop valves.
Wolff et al 7
Authors Note
Creation of this article is supported with resources and the use
of facilities at the US Department of Veteran Affairs National
Center for Patient Safety Field Office in White River Junction,
Vermont. The views expressed in this article do not necessarily
represent the views of the Department of Veterans Affairs, the
US government, or Dartmouth College.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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