Flash Burns While on Home Oxygen Therapy: Tracking Trends and Identifying Areas for Improvement

Am J Med Qual. Jul/Aug 2017;32(4):445-452. doi: 10.1177/1062860616658343. Epub 2016 Jul 11.


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: flash burn; harm reduction; home oxygen therapy; nicotine addiction; shared decision making.

MeSH terms

  • Aged
  • Burns / etiology*
  • Equipment Design
  • Home Care Services / standards*
  • Home Care Services / statistics & numerical data*
  • Humans
  • Middle Aged
  • Oxygen Inhalation Therapy / adverse effects*
  • Patient Education as Topic / organization & administration
  • Patient Safety*
  • Retrospective Studies
  • Risk Assessment
  • Root Cause Analysis
  • Smoking / epidemiology
  • United States
  • United States Department of Veterans Affairs