LUMITEX MD LIGHTMAT SURGICAL ILLUMINATOR

Description of Event or Problem

A LIGHTMAT SURGICAL ILLUMINATOR BY LUMITEX MD (REF#UA2550, LOT 102659) WAS BEING USED DURING A BILATERAL MASTECTOMY PROCEDURE. THE ILLUMINATOR WAS CONNECTED TO A GYRUS ACMI G93 4 MM FIBER OPTIC LIGHT CABLE WHICH WAS CONNECTED TO AN INTEGRA LUXTEC 300 MLX XENON LIGHT SOURCE. THE SURGEON NOTED DURING THE FIRST PART OF THE PROCEDURE THAT THE ILLUMINATOR LIGHT WAS DIM. IT WAS THEN NOTED THAT THE SKIN OVER THE STERNUM HAD BEEN BURNED. THE METAL CONNECTION BETWEEN THE LIGHT CABLE AND THE ILLUMINATOR APPEARED TO HAVE COME IN CONTACT WITH THE SKIN IN THE AREA OF THE STERNUM. THE BURN COVERED AN ESTIMATED 4 X 3 CM AREA THAT APPEARED TO BE MOSTLY SUPERFICIAL AND PARTIAL THICKNESS. AN ESTIMATED 2 X 1 CM PORTIONS OF THE BURN INJURY APPEARED TO BE A FULL THICKNESS BURN. THERE WERE ALSO A COUPLE OF VERY SMALL, PUNCTATE AREAS OF BURN ON THE LEFT UPPER CHEST WALL.