Previously reported as voluntary report (b)(4).Received notice one week ago from an attorney of intent to sue and accompany death certificate.Re-reporting as a mandatory report.Cause of death chf complicated by thermal injuries.Pt first had a removal of temporary pacemaker leads and removal of temporary dialysis cath on the left side.An hour after, the pt was prepped on the left side for placement of a permanent pacemaker.Chloraprep 10.5 ml used on the right side, chloraprep 26 ml used on the left side.After prepping with chloraprep, scrub tech laid surgical towels on the shoulder and went to scrub and get lead apron.At 10-15 minutes later, tech continued with the rest of the sterile field and layout of 3m ioban 2 surgical drape.Placed pacemaker drape and towels.Nurse set up oxygen supply at 15lmp non-rebreather with bag towards the head instead of the feet to clear space for sterile field for procedure.Applied esu return pad to right thigh and connected it to the esu generator.Esu set to 35 watts in cut and coag modes.Esu pencil connected and placed in holster in the surgical field.Esu generator set for use in monopolar mode.After physician scrubbed and gowned, surgical curtain hung over the holder.Physician injected about 20cc of lidocaine cocktail and made three incisions.Picked up the esu pencil to control some bleeders.Activated the pencil by pressing the button in the pencil's handle.Saw a spark flash from the pencil's tip toward the sterile field and up the pt's chin area.Within a second, a flash fire occurred through the surgical towels and the 3m ioban 2 surgical drape, flames shot out of the mask's tubing and burst the facemask bag.Fire noted around the pt's facemask and hair.Set up of burning surgical drape removed and stomped out while the nurse turned the oxygen source off.Fire took 10-15 seconds to extinguish.Fire resulted in thermal burns to face and neck.Pt intubated to protect airway and transferred to a burn center.Changed from a voluntary report to mandatory after further details received.
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