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ProAssurance Risk ManagementJanuary 20244 min read

Surgical Never Event - Electrocautery Ignites Alcohol-Based Surgical Prep

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 fires in the following case study.


The patient sued all members of the surgical team, including the attending and the hospital, alleging improper supervision of the resident and failing to recognize the fire risk resulting in significant and disfiguring permanent scarring.

Case File

Under the attending’s supervision, a resident was scheduled to remove fatty tumors on the patient’s head and neck. The patient was intubated and prepped with an alcohol-based solution. Shortly after the prep was completed, the resident applied the electrocautery tip to the tumor at the patient’s hairline, which ignited a fire in the patient’s hair and across her face. The fire was quickly extinguished, but the patient sustained second-degree burns across her face, which caused significant and disfiguring permanent scarring.


Although the resident was in the best position to prevent this fire from occurring, the attending was directly liable due to his supervisory role and vicariously liable because he was the captain of the ship. Unfortunately, the attending was not in the habit of reminding residents that they needed to wait for at least the period of time designated on the prep solution packaging to allow the alcohol fumes to dissipate prior to using electrocautery. According to experts, the resident (or the attending) should have confirmed that the appropriate waiting time was observed and that there was no remaining prep solution or vapors in the area of the operative site. The nurse who had prepped the patient, knowing the prep solution was in the patient’s hair and that it had not had adequate time to dry, also should have warned the resident as he prepared to use the electrocautery device.

Risk Reduction Strategies

Consider the following strategies:1,2,3

  • Be familiar with the time requirements of all of the prep solutions you use. If you do not know the requirement, ask the circulator.
  • Confirm with the other members of the surgical team that prep solutions have dried and vapors have dispersed before using an electrocautery device.
  • If you are the attending or supervising physician, remind trainees of surgical fire prevention protocols.

Person Applying the Surgical Prep Solution
  • Warn the surgeon preparing to use an electrocautery device to wait until the prep solution has had adequate time to dry.
    • Consider setting a timer to ensure adequate drying times are observed.

Surgical Fire Resources

This content originally appeared in Claims Rx, our claims-based learning publication available in the searchable Claims Rx Directory. Many releases are available for download and eligible insureds will find instructions for obtaining CME credit for select releases.

1 U.S. 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.