Surgical fires occur in a wide variety of medical settings, from solo practices to large hospitals. Surgical fire prevention depends mostly on fire risk awareness and communication among the members of the surgical team.
Any team member can prevent or contribute to a surgical fire because elements of the fire triangle — air (oxygen), fuel (prepping solution, drapes, patient skin), and ignition source (electrosurgical units) — are generally controlled by different members of the surgical team. Therefore, all team members should think about how their actions might complete the fire triangle that leads to these never events and should communicate with other team members about fire risk status throughout the surgery. Consider how the various surgical team members could have prevented the fire in the following case study.
Allegation
The patient sued the dermatologist, the nurse, and the surgical center where the procedure took place alleging failure to recognize the fire risk when switching to an aerosol anesthetic resulting in permanent disfiguring injuries.
Case File
A patient presented to her dermatologist for minor surgery to remove a skin cancer lesion on her shoulder. It was discovered at the last minute that the patient was allergic to most IV anesthetics. Therefore, instead of rescheduling with general anesthesia, the dermatologist determined she could go forward with an aerosol topical anesthetic. The nurse applied the anesthetic under the physician’s direction. Shortly after surgery started, the electrocautery unit ignited a flame, which flashed across the surgical field. The patient sustained permanent disfiguring injuries.
Discussion
Seemingly minor office procedures can result in disfiguring surgical fires. During discussions with the dermatologist following the fire, the nurse admitted that she did not think the aerosol anesthetic was flammable. The nurse was in the best position to warn the dermatologist of the product’s flammability, but she failed to do so, only reading the directions for use on the container. Further foreclosing the chance that the flammability would be discovered, the nurse had placed a patient identification sticker over the large warning about the product’s flammability. Without the sticker, the dermatologist may have seen the warning, since she directed the nurse’s application of the product. The dermatologist would share liability with the nurse in this case, as she was the one who ordered the use of the product, supplemental oxygen, and cautery without taking adequate fire safety precautions.
Risk Reduction Strategies
Consider the following strategies:1,2,3
Physicians
- Follow fire safety protocols any time an ignition source is used during a procedure.
- Be aware of the flammability of products you use on patients.
- Follow fire safety instructions in product packaging.
Staff
- Warn physicians of the flammability of a product when the physician is going to use electrocautery without taking appropriate fire safety precautions.
Administrators
- Ensure that physicians and staff are aware of the flammability of products used during surgery.
- Inspect the labels on flammable products. If the flammability is not prominent, affix additional warning labels and directions to decrease fire risk.
Surgical Fire Resources
Guidelines
- American Society of Anesthesiologists (ASA). Practice Advisory for the Prevention and Management of Operating Room Fires: An Updated Report by the American Society of Anesthesiologists Task Force on Operating Room Fires.
- US Food and Drug Administration. “Recommendations to Reduce Surgical Fires and Related Patient Injury: FDA Safety Communication.”
- Pennsylvania Patient Safety Authority. “Surgical Fires: Decreasing Incidence Relies on Continued Prevention Efforts.”
- Pennsylvania Patient Authority and ECRI “Update on Clinical Guidance for Surgical Fire Prevention and Management” video.
Tools
- Council on Surgical & Perioperative Safety. Safe Surgery Resources. “#7: Fire Safety.”
- Association of periOperative Registered Nurses (AORN). “Fire Safety Toolkit” toolkit.
- Pennsylvania Patient Safety Authority. “Patient Safety Topics: Fires, Surgical.”
- ChristianaCare. “Surgical Fire Risk Assessment.”
- ECRI Institute. “Only You Can Prevent Surgical Fires” poster.
- Anesthesia Patient Safety Foundation (APSF). “OR Fire Prevention Algorithm” poster.
More Information About Preventing Never Events
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References
1. US Food and Drug Administration. “Recommendations to Reduce Surgical Fires and Related Patient Injury: FDA Safety Communication.” 2018.
2. Mark E. Bruley, et al. “Surgical Fires: Decreasing Incidence Relies on Continued Prevention Efforts.” Pennsylvania Patient Safety Authority. Pennsylvania Patient Safety Advisory. 2018;15(2).
3. Institute for Safe Medication Practices. “Surgical Fires Caused by Skin Preps and Ointments: Rare but Dangerous and Preventable.” March 8, 2018.