|Title:||Healthcare Inspection - Issues Related to Ultraviolet Germicidal Irradiation Light Exposure in an Operating Room, Lebanon VA Medical Center, Lebanon, PA|
|VA Office:||Veterans Health Administration (VHA)
|Report Author:||Office of Healthcare Inspections
|Report Type:||Healthcare Inspections
The OIG conducted an inspection to determine the validity of allegations that a surgical patient and 10 Lebanon VAMC employees suffered injury due to Ultraviolet Germicidal Irradiation (UVGI) light overexposure.
We substantiated the allegation that Operating Room (OR) staff was harmed on January 17, 2012, as a result of inadvertent UVGI light overexposure, but the patient was not, because he was protected from ultraviolet light exposure (UV) by surgical drapes. Affected facility staff suffered temporary blindness, eye irritation, or skin burns. The extent of the overexposure was not known until the following morning when the staff noticed symptoms of overexposure from the UVGI lights. We found that facility leadership acted promptly by reporting the incident, notifying and referring employees for care, and disabling the UVGI light switch.
We did not substantiate the allegation that facility management was previously warned about potential safety hazards from UVGI light overexposure.
We substantiated the allegation that there were no warning labels on the UVGI light switch.
Facility leaders took immediate action to disconnect UVGI lights the same day exposures were reported. We made no recommendations.