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<p>Microwave ablation is a widely utilized treatment for hepatocellular carcinoma, offering favorable clinical outcomes. However, complications can arise, necessitating vigilance and strict adherence to safety protocols. We report a case involving a 63-year-old male patient with hepatitis B-related hepatocellular carcinoma who underwent scheduled microwave ablation for liver lesions. Postoperatively, a large necrotic area was identified on his back, subsequently diagnosed as a third-degree burn. Root cause analysis identified multiple procedural and systemic failures, including the use of an excessively long antenna relative to the patient’s body habitus, inappropriate high energy settings, and involvement of an inexperienced clinical team. These factors aligned, as described in the Swiss cheese model, leading to patient harm. This case underscores the importance of situational awareness and proactive patient advocacy in preventing medical errors. Promoting a culture in which all team members feel empowered to speak up, particularly during high-risk procedures, is essential to ensuring patient safety. Each healthcare professional contributes a unique and indispensable perspective and should be encouraged to act as a patient advocate, even when concerns extend beyond their immediate clinical responsibilities.</p>

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Cutaneous Burn Post Microwave Ablation: a Case Report on Patient Safety

  • 期刊论文

  • 发表日期：

    2025年8月2日

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  • Fotios Vlahos,
  • Vasiliki Kalogianni,
  • Iosifina Giannakikou

摘要

Microwave ablation is a widely utilized treatment for hepatocellular carcinoma, offering favorable clinical outcomes. However, complications can arise, necessitating vigilance and strict adherence to safety protocols. We report a case involving a 63-year-old male patient with hepatitis B-related hepatocellular carcinoma who underwent scheduled microwave ablation for liver lesions. Postoperatively, a large necrotic area was identified on his back, subsequently diagnosed as a third-degree burn. Root cause analysis identified multiple procedural and systemic failures, including the use of an excessively long antenna relative to the patient’s body habitus, inappropriate high energy settings, and involvement of an inexperienced clinical team. These factors aligned, as described in the Swiss cheese model, leading to patient harm. This case underscores the importance of situational awareness and proactive patient advocacy in preventing medical errors. Promoting a culture in which all team members feel empowered to speak up, particularly during high-risk procedures, is essential to ensuring patient safety. Each healthcare professional contributes a unique and indispensable perspective and should be encouraged to act as a patient advocate, even when concerns extend beyond their immediate clinical responsibilities.