Iatrogenic burn injuries in hospital, a preventable and costly hazard

Dr Dylan Prunster1, Dr Peter Meier1, Mr Graeme Mcleoud1, Dr Helen Douglas1, Mr Jeremy Rawlins1,2

1Fiona Stanley Hospital – State Burns Service of Western Australia , Perth, Australia, 2President of The Australian & New Zealand Burns Association



Iatrogenic burns are defined as any burn injury that occurs whilst receiving treatment in a medical facility or whilst using medical equipment. Hospital related iatrogenic burns are thought to be underreported worldwide, with the exact incidence unknown (Zhang, et al., 2009; Anderson et al., 2021). Although uncommon, they significantly increased the morbidity, the length of admission and financial burden to the public hospital system (Anderson et al., 2021). The aim of our audit was to assess the incidence, mechanism of iatrogenic burns and financial cost related to their treatment in the Western Australian Burns Service.

Materials & Methods

Data were retrospectively collected on 25 consecutive patients treated with iatrogenic burns between 2016 and 2021 from the Western Australia State Burns Centre database for analysis in this audit. The patients’ following demographics, total burns surface area (TBSA), mechanism of injury, and financial cost were analysed.


During the audit period, a total of 25 (8 male, 17 female) patients were treated for burns acquired in hospital. The average TBSA was 0.5%, the most common mechanism of injury was from tourniquet (5) and contact burns (5), followed by chlorhexidine preparation burns (4), theatre fires (3), with the remaining a mix of mechanisms (8). Nineteen occurred in a theatre, one patient was the victim of two iatrogenic injuries, and one patient had a procedure cancelled after a theatre fire. The average cost of each iatrogenic burn requiring inpatient admission was $27,082, the average cost for patients managed in an outpatient setting was $281.95. Total costs for the combined cohorts totalled $301,568.


Iatrogenic burns constitute a significant morbidity and financial burden to the public health system in Western Australia. Despite the focus shifting in recent times to the focus on promoting and empowering a culture of safety within hospitals and more specifically theatre environments, further education to actively reduce the risk of iatrogenic injuries is clearly required.


Dr Dylan Prunster is a surgical service registrar working within the West Australian Health Department with a keen interest in Plastic and Reconstructive Surgery. He obtained his primary medical qualification from the University of Western Australia and subsequently undertook an internship and residency at Royal Perth Hospital.

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