PHOTONGUIDE

Description of Event or Problem

DURING A LUMPECTOMY PROCEDURE, IT WAS NOTED THAT THE PLASTIC DISPOSABLE END PIECE OF THE PHOTONGUIDE HAD BROKEN OFF AND THE LIGHT, FROM THE BREAST RETRACTOR, BURNED THE SKIN OF THE PATIENT. THE BROKEN PIECE WAS FOUND ON THE SURGICAL DRAPE AND PASSED OFF THE FIELD. THE LIGHT RETRACTOR WAS IMMEDIATELY TURNED OFF. THE SURGEON ASSESSED THE BURN, AND APPLIED BACITRACIN OINTMENT AT THE END OF THE PROCEDURE.