Halogen lights emit ultraviolet light and must have filters to remain safe. However, staff at the hospital had changed the lights and left them without the necessary filters, according to the report.
The first patient who experienced the burn reported it in June 2014, but an investigation did not uncover the source of the problem for about five months.
The affected patients experienced mild burns, and the only permanent damage done was redness of skin, according to the report.
To prevent this patient safety issue in the future, Silverton Hospital replaced the halogen lights with lamps using light-emitting diodes and change some processes. No one was fired as result of the incidents, because “it was a system issue, not an individual issue,” Ray Willey, the hospital’s director of quality and risk services, said in the report.
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