Patient Safety Tip of the Week

December 13, 2011

Surgical Fires – Again



Barely a month after the FDA launched a new initiative aimed at preventing surgical fires (see our November 2011 What’s New in the Patient Safety World column “November 2011 FDA Initiative on Preventing Surgical Fires”) 2 new high-profile surgical fires were in the news.


A 29 y.o. Florida woman suffered serious face and neck burns during surgery to remove several cysts on her head (NineMSM News 2011). Medical and procedural details are not available. Less than a week later, a similar event occurred in Washington state involving a man having a “lump” removed from his head (Hopperstad 2011). The patient said he believes the cauterizing tool used in the surgery caused a spark and that, in turn, ignited the oxygen in his oxygen mask. These two cases graphically illustrate the devastating effects such surgical fires have on patients.


See our December 4, 2007 Patient Safety Tip of the Week “Surgical Fires” for a comprehensive description of the factors involved in surgical fires. The fire “triangle” has 3 elements: heat, fuel and oxydizer. In general, each member of the surgical team – the surgeon, the anesthesiologist, and the nurses – controls a specific side of the triangle. That is, the surgeon controls the heat source, the nurse the fuel source, and the anesthesiologist the oxidizer. The heat source is most often an electrocautery instrument or electrosurgical unit or a laser but drills, heated probes, and even fiberoptic light sources and others may be heat sources. In addition, sparks and embers may serve as potential igniters. Almost anything in the OR can burn and be a source of fuel. The closer the heat source is to the oxygen source, the greater the risk of fire. Hence, surgeries involving the head, neck or upper chest are most vulnerable. That column also had links to the many great resources available through the ECRI Institute, the most renowned authority on surgical fires.


In our November 2009 What’s New in the Patient Safety World column “ECRI: Update to Surgical Fire Prevention” we noted ECRI’sNew Clinical Guide to Surgical Fire Prevention”. The 2009 key change in clinical practice was discontinuing the open delivery of 100% oxygen during procedures done under sedation. They discuss ways to minimize the concentration of oxygen being used in a variety of scenarios. But essentially it says that if significant oxygen is needed during a procedure being done under conscious sedation, it should be delivered via a secure airway (endotracheal tube or laryngeal mask). It is not clear whether those guidelines were followed in the 2 recent fires in the news.


Given the potentially devastating consequences of surgical fires, it is essential that all appropriate steps be taken to prevent them. This starts by identifying those cases at high risk for surgical fire. We recommend that a surgical fire risk assessment be done on every case. This can be done at either the pre-surgical “huddle” or the surgical timeout. We favor it be done at the huddle, but only if all the key players (surgeon, anesthesiologist, and nurse) are participating in that huddle (as they should be!). This is, of course, necessary because if the case is a high-risk case for surgical fire each of those participants must understand what their role is in the event a fire should occur. In addition, the surgeon and anesthesiologist must be on the same page and understand when oxygen flow must be minimized or ceased prior to use of a heat source. Coordination between the anesthesiologist and surgeon are critical when it comes to using lasers, electrocautery tools, electrosurgical tools, or other potential sources of ignition. The surgeon should give adequate notice that he/she is about to use such a device and then adequate time should be allowed to elapse to allow the anesthesiologist to take steps to minimize the oxygen in the area.


The tool we really like is the one used at the San Francisco VA system (see our January 2011 What’s New in the Patient Safety World column “Surgical Fires Not Just in High-Risk Cases”). As part of an effort to promote fire safety in the OR (Murphy 2010), the San Francisco VA developed a checklist “The Surgical Fire Assessment Protocol”. This checklist/protocol is actually printed on the reverse side of their larger preoperative checklist. The fire risk is assessed by a simple numerical scale. If the score is 3 (high risk) the rest of the form is filled out, which basically delineates the respective roles of all those participants. That’s a really good way to remind all about their responsibilities if a fire occurred.


An alternative tool was described in the video accompanying the new FDA initiative that we discussed in our November 2011 What’s New in the Patient Safety World column “November 2011 FDA Initiative on Preventing Surgical Fires”. That video on surgical fires focuses on an approach taken by one healthcare organization after it experienced two surgical fires within an 8-month period. They incorporated a fire risk assessment into their Universal Protocol so that it gets done on virtually all surgical cases. The risk assessment is based on 3 simple questions about the fire triangle: (1) is there an open oxygen source? (2) is there a heat source present? and (3) how close are they to each other? (Note they assume that the “fuel” leg of the fire triangle is everpresent in the OR.) They then tie various protocols to the risk assessment score. The video describes the steps taken to mitigate the fire risk and also deals with improving communication among all members present in the OR and changing safety culture.


The American Society of Anesthesiologists’ Practice Advisory for the Prevention and Management of Operating Room Fires stresses that all anesthesiologists should have fire safety education, specifically for OR fires, with an emphasis on the risk created by an oxidizer-enriched atmosphere (see our April 29, 2008 Patient Safety Tip of the Week “ASA Practice Advisory on Operating Room Fires”). OR fire drills should take place with the entire OR team. Very importantly, the advisory recommends that for each case, the OR team should formally (1) determine whether or not a high-risk situation exists and (2) have team discussion about strategy for prevention and management of a fire. And a protocol for prevention and management of fires should be placed visibly in each location where surgery/procedures might be done, along with all appropriate equipment for managing a fire. Each member of the team should be assigned a task and understand they should perform that task immediately without waiting for other team members to act. (Once they have completed their task, they can help other team members with other tasks). Though there is no evidence base to confirm that such a pre-case team discussion actually prevents or helps manage fires, it’s certainly good common sense. For those of you who like checklists, it’s a good item to add to your preoperative checklist.



The other critical consideration in surgical fires typically has to do with skin preparations used. Most modern skin preparations contain alcohol, which is flammable. It’s therefore essential that adequate time be allowed for drying of areas prepped with alchohol-based solutions. And one must ensure that any alcohol vapors have disseminated as well. Here there are often subtleties. One of the most popular skin prep agents comes in varying sizes of applicators. The ratio of chlorhexidine to isopropyl alcohol is that same in both instances. What is different is the size of the applicator and, hence, the total amount of isopropyl alcohol. The larger applicator has a warning in small print on its package “not to be used in surgery of the head and neck” but otherwise the applicator packages look the same.



We suspect a certain level of complacency may play a role in many surgical fires. They are often is cases very similar to the 2 in the headlines recently – considered relatively minor, routine procedures, often performed under conscious sedation. Such cases are often “add-ons”, cases added onto a surgical schedule when time permits following more complex cases. In such cases, we often let our guard down. Unless we are rigorous in formally including a fire risk assessment in each and every case, it’s easy to see how risk factors for fires may be overlooked.


Prevention of surgical fires requires an ever-present vigilance for risk factors, protocols to minimize those risks, and simulation training or drills so that all staff know what to do if a fire does occur. Surgical fires are uncommon enough for staff to be poorly trained at both prevention and response once one actually occurs. Yet they are frequent enough that most OR staff will encounter one or more in a lifetime. Only with meticulous steps to minimize fire risk, identification of fire risk for each individual case, training and drills will OR staff be prepared to do what it takes to prevent fires and know their roles in responding immediately if a fire occurs.



Lastly, don’t forget the impact of surgical fires on all the staff in the operating room. They all went to the OR that day with the intention of helping patients, then witnessed these horrific incidents that they will never forget. That’s one reason we try to educate staff about this risk before an event occurs. When they watch a surgical fire video or see photographs of the victims of such fires or a charred, melted endotracheal tube they typically say “Wow. I don’t ever want one of those to happen here.”



There are many great resources available now on surgical fires. In addition to the ECRI Surgical Fire Prevention website and the new FDA Surgical Fires website, there is the AORN Surgical Fire Tool Kit and the Anesthesia Patient Safety Foundation video on prevention and management of operating room fires.





Please also see our prior columns on surgical fires:


Patient Safety Tips of the Week:

·        December 4, 2007       Surgical Fires

·        April 29, 2008 ASA Practice Advisory on Operating Room Fires


What’s New in the Patient Safety World columns:

·        November 2009           ECRI: Update to Surgical Fire Prevention

·        January 2011                Surgical Fires Not Just in High-Risk Cases

·        March 2011                 APSF Fire Safety Video

·        November 2011           FDA Initiative on Preventing Surgical Fires







NineMSM News staff. Woman's face burned during routine surgery. NineMSM News 2011; December 3, 2011



Hopperstad J. Washington man's face catches fire during routine surgical procedure. Q13 FOX News  December 5, 2011



ECRI. Surgical Fire Prevention. 2009 update.



Murphy J. A New Effort to Promote Fire Safety in the OR.

Topics In Patient Safety (TIPS) 2010; 10(6): 3



SF VAMC Surgical Fire Risk Assessment Protocol



Silverstein KL, Joseph S. FDA on Medscape: Surgical Fires: How They Start and How to Prevent Them. October 12, 2011



American Society of Anesthesiologists Task Force on Operating Room Fires. Practice Advisory for the Prevention and Management of Operating Room Fires. Anesthesiology 2008; 108: 786-801



FDA. Preventing Surgical Fires.



ECRI Institute. Surgical Fire Prevention.



AORN (Association of periOperative Registered Nurses). Fire Safety Tool Kit.



Anesthesia Patient Safety Foundation. Fire Safety Video.



















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