Surgical Never Event - Electrocautery Ignites Supplemental Oxygen

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 all members of the surgical team and the surgery center alleging failure to recognize the risk of firing the electrocautery unit without discontinuing supplemental oxygen led to corrective surgeries and permanent facial scarring.

Case File

A patient presented for temporal artery biopsy. There was no pre-surgical time out, briefing, or fire risk discussion. IV sedation and supplemental oxygen via nasal cannula were started. A couple of minutes into the procedure, the surgeon requested the electrocautery unit from the circulating nurse. The surgeon then tested the unit and saw it displayed a glowing tip. He did not announce that he was going to fire the device, and the anesthesiologist did not discontinue the supplemental oxygen in anticipation of the ignition. A flash fire occurred when the cautery unit was fired in the operative site. The fire was quickly extinguished; however, the patient sustained second- and third- degree burns on his nose, cheek, and mouth. The patient underwent multiple corrective cosmetic surgeries, but sustained permanent facial scarring.

Discussion

Many closed claims at NORCAL Group (now part of ProAssurance) concerning surgical fires involve surgery above chest level, supplemental oxygen, and an electrocautery device. Any time supplemental oxygen and an electrocautery device are being used together — particularly when the surgery is taking place above chest level — everyone on the operating team should be on high alert and ready to warn the team when fire safety precautions are not being observed. According to experts, the surgical team missed multiple opportunities to prevent this surgical fire, including:

• The surgeon failed to lead a discussion about the high risk nature of this procedure. (“High risk” is defined as a procedure in which an ignition source could come in proximity to an oxidizer-enriched atmosphere.¹)
• The anesthesiologist failed to request a time out and lead the fire risk discussion when the surgeon failed to do so.
• The surgeon failed to ask the anesthesiologist to discontinue the oxygen in anticipation of the electrocautery unit use.
• The anesthesiologist, who was close enough to the surgeon to have heard him request the electrocautery unit from the circulating nurse and saw him test the unit in anticipation of using it, failed to discontinue the oxygen independently and failed to advise the surgeon to wait to use the electrocautery device until the oxygen could adequately dissipate.
• The circulating nurse, who admitted during her deposition that she generally did not pay attention to what the surgeon was doing after she set out an electrocautery unit, failed to advise both physicians of the fire risk involved with using the electrocautery device with supplemental oxygen still flowing.
• The surgeon and anesthesiologist failed to follow the surgery center policy prohibiting electrocautery use around the face with supplemental oxygen.
• The surgery center failed to communicate its own fire safety policies and procedures to the members of the surgical team and ensure compliance.
  
  

Risk Reduction Strategies Recommendations

Consider the following strategies:^1,2,3

Surgeon

• Conduct a fire risk assessment involving the entire surgical team prior to the start of surgery, which can be included in the preoperative briefing or the time out.
  • Discuss any instruments being used that increase the risk of surgical fire.
  • Discuss supplemental oxygen use.
    • Question the necessity of supplemental oxygen when appropriate.
  • If the procedure is high-risk, plan for how a fire will be managed.
  • Use a surgical fire safety checklist.
  • Refer to a surgical fire safety algorithm.
• Before activating a potential ignition source, when the patient is receiving supplemental oxygen, tell the anesthesiologist that it is about to be activated. Do not activate it until the anesthesiologist has confirmed that it is safe to do so. For example:
  • Surgeon: “Turn down the oxygen concentration. I am getting ready to use electrocautery.”
  • Anesthesiologist: “The oxygen has been titrated to as close to 21% as possible. The patient’s SATs are still acceptable. You may use the cautery.”

Staff

• If a fire risk discussion is not initiated prior to surgery, request that one takes place.
• During the pre-surgical fire risk discussion, raise fire risks specific to your role in the procedure.
• Maintain awareness of fire risks that arise during surgery and give warnings when appropriate.
  
  

Administrators

• Provide surgical fire safety policies and protocols.
• Ensure compliance with surgical fire safety policies and protocols.
• Schedule drills to practice fire safety communication.
• Post a protocol for the prevention and management of fires in the operating room to reinforce actions covered in drills and educational training.
  
  

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.”
• “Surgical Fire Risk Assessment.”
• ECRI Institute. “Only You Can Prevent Surgical Fires” poster.
• Anesthesia Patient Safety Foundation (APSF). “OR Fire Prevention Algorithm” poster.
  
  

1. Jeffrey L. Apfelbaum, et al. “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.” Anesthesiology. 2013;118: 271-290. DOI: 10.1097/ALN.0b013e31827773d2

2. US Food and Drug Administration. “Recommendations to Reduce Surgical Fires and Related Patient Injury: FDA Safety Communication.” 2018.

3. 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).