Patient Safety Tip of the Week

December 4, 2007          Surgical Fires




When the Pennsylvania Patient Safety Reporting System reported on 3 “never” complications of surgery that, in fact, occurred surprisingly frequently, many of us were not surprised by the frequency of wrong-site surgery or retained foreign bodies. However, most of us were quite surprised by the frequency of surgical fires. The PSRS had an average of 28 surgical fires per year in Pennsylvania and calculated the incidence to be 1 per 87,646 operations.



Two organizations, Joint Commission and ECRI, have really taken the lead on bringing this issue to the fore. Not only are most surgical fires preventable, but understanding the correct response to a surgical fire that does occur is essential since an improper response can actually result in more patient harm and even staff harm.



ECRI Institute has done many years of research on surgical fires and has published numerous alerts, tips and recommendations on their prevention and response to surgical fires. The ECRI publication “The Patient is on Fire! A Surgical Fires Primer” is a comprehensive document that all organizations or facilities performing surgery must read. ECRI also has a guideline “A clinican’s guide to surgical fires: how they occur, how to prevent them, how to put them out” available from the National Guideline Clearinghouse. After reading these, you won’t want to let anyone in the OR who has not been properly trained and prepared in surgical fire prevention and fire response! It’s actually quite frightening to think how easily fires can start and spread in the OR. While a fire theoretically could occur anywhere in the OR, such as at an oxygen source, in the real world almost all surgical fires occur on or around the patient.



Joint Commission issued a Sentinel Event Alert in 2003 addressing surgical fires. That alert contains many recommendations on how to prevent surgical fires. A subsequent document on FAQ’s for the 2007 National Patient Safety Goals makes numerous additional recommendations on steps to prevent surgical fires.



Joint Commission National Patient Safety Goals specifically require surgical fire prevention only for Ambulatory Care Accreditation and Office-Based Surgery Accreditation but Joint Commission strongly recommends that all hospitals adopt the recommendations. A 2005 article in the Joint Commission Journal of Quality and Patient Safety “Preventing Surgical Fires: Who Needs to be Educated?” from the University of Michigan and Ann Arbor VA Healthcare System provide an excellent discussion Another Joint Commission Resources article notes several examples of how vigilence by all staff in the OR can be important in reducing the likelihood of 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 ECRI primer noted above lists many of those items. However, certain especially volatile and flammable substances are implicated more often than others. For instance, many of the prepping solutions are alcohol-based and the liquid alcohol is volatile so its vapors may be trapped under drapes, etc., where they can become easily ignited. And the oxidizers include not only oxygen, but also nitrous oxide. Any area with an oxygen concentration higher than 21% is known as an oxygen enriched environment and fires in such are easier to ignite and burn faster.



Prepping and draping the patient are extremely important. Care must be taken to ensure that any volatile liquids have fully evaporated and drapes be properly placed to avoid collection of the vapors under the drapes.



Use of oxygen needs to be minimized and the drapes appropriately tented about the patient’s head to allow air circulation to dilute the oxygen.



Electrosurgical or electrocautery tools and lasers must be kept away from the patient and table when not in active use. Everyone in the OR needs to remain vigilant to ensure these heat sources are not inadvertently in proximity to a dangerous situation. Most have holsters or other devices that deactivate them when not in use. Many also have audible alerts that indicate when they activated.



The ECRI primer provides details on how to respond to fires in the OR. Having a fire plan and specifically running fire drills for surgical fires is crucial. Most hospitals conduct general fire drills several times a year. However, very few actually conduct drills to specifically prepare for a surgical fire. ECRI provides a useful poster “Only You Can Prevent Surgical Fires” and everyone who works in the OR needs specific training on surgical fires. However, given the seriousness of surgical fires and the speed with which the events unfold, there is no substitute for rehearsing for surgical fires in formal drills.




Airway fires are a special danger in the OR. The March 2007 Pennsylvania Patient Safety Authority Advisory shows shocking photographs of a trachea tube that had been ignited during a trachostomy and another showing a demonstration of a trachea tube turned into a blow torch after being ingited by a laser while 100% O2 was flowing. That advisory provides specific actions to minimize the risk of airway fires. Such fires are extremely hazardous to the patient, capable of causing severe harm and death. The advisory details the coordinated steps the OR team must take immediately in the event of airway fires, including stopping gas flow, removing the tracheal tube, maintaining airway patency, extinguishing the fire, and care and assessment of the patient, including bronchoscopic examination. Another poster “Airway Files during Surgery” is also available through the Pennsylvania PSA.



And keep in mind that burns may occur on patients even in the absence of a fire. An AHRQ Web M&M Case and Commentary describes how a laparoscope temporarily placed on a tray on the patient while the trocar was being repositioned resulted in a patient burn. The discussion provides excellent lessons about heat source and surgical fire potential in the laparoscopy setting.



ECRI and the Pennsylvania PSA also have several other articles on specific aspects of surgical fires, including excellent references and resources. These include “Risk of Fire from Alcohol-Based Solutions”, “Electrosurgical Units and the Risk of Surgical Fires”, and “Electrosurgery Safety Issues”. AORN also produces an excellent toolkit, the “Perioperative Fire Safety Tool Kit”.



Surgical fires are no laughing matter and they occur frequently enough that your facility may encounter one at some point. The consequent patient injury may be substantial, including the potential for death. You need to incorporate specific surgical fire training into your orientation programs and ensure that all staff coming to your OR’s have had that training. That includes housestaff and other people that may periodically rotate through your facilities. You should also perform specific surgical fire drills regularly so that staff know how to respond promptly and correctly should a surgical fire actually occur.





Update: See April 29, 2008 Patient Safety Tip of the Week “ASA Practice Advisory on Operating Room Fires







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