Description of Event or Problem · 1
REPORT OF PATIENT HAVING CAUTERY PROCEDURE OF HER VAGINAL CONDYLOMA AND EXCISION OF VULVAR CONDYLOMA WITH A SHARPLAN CO2 LASER. PRIOR TO THE CASE THE LASER WAS TESTED BY TWO RN'S. DURING THE TEST THE LASER SHOWED 2 RED AIMING BEAMS INSTEAD OF THE USUAL ONE BEAM. WHEN THE BEAM WAS FIRED ON THE TEST STICK ONLY THE LEFT AIMING BEAM BURNED THE STICK. THE DOCTOR CAME IN AND LOOKED AT THE LASER PRIOR TO THE CASE TO DETERMINE WHETHER OR NOT HE STILL WANTED TO USE IT. HE DECIDED THAT HE DID AND PROCEEDED WITH CASE. UPON DOCTOR'S FIRST ATTEMPT AT USING LASER ON AFFECTED CONDYLOMA, THE LASER DID SPLIT INTO TWO BEAMS AND CAUSED VAPORIZATION OF TISSUE IN BOTH LOCATIONS, RATHER THAN ONE AS ON THE TEST STICK. THIS RESULTED IN A MINOR BURN TO PT'S LEFT LABIA MAJORA AS WELL AS THE INTENDED CONDYLOMA. LASER USE WAS DISCONTINUED AND OBGYN ASSESSED THE BURN. MD AND OR STAFF AGAIN INSPECTED THE LASER AND COULD NOT DETERMINE WHY LASER BEAM HAD BIFURCATED. CASE PROCEEDED WITH USE OF ELECTROCAUTERY TO CONDYLOMA AND OTHER LESIONS. DEVICE SENT TO CLINICAL ENGINEERING FOR EVALUATION. MANUFACTURER'S TECH CAME ONSITE A FEW DAYS LATER AND REALIGNED BEAM AND MADE SOME SLIGHT ADJUSTMENTS. DEVICE WILL BE PLACED BACK INTO SERVICE ONCE OUR OFFICE RECEIVES A SERVICE REPORT FROM MFG. TECH. PATIENT WAS DISCHARGED LATER THE SAME DAY WITHOUT ANY FURTHER ISSUES OR COMPLAINTS.