Published in The Joint Commission
By Gerard M. Castro, PhD, MPH
Out of approximately 65 million surgical cases annually, there are 200 to 240 surgical fires, a frequency comparable to that of other surgical safety events such as wrong site surgery and unintended retention of a foreign object.1 While relatively rare, surgical fires can be catastrophic, causing death or serious permanent harm to patients. Nearly all of these events are preventable. Careful planning and awareness can help reduce the risk.
National Fire Prevention Week
National Fire Prevention Week (NFPW) is a good time to do a quick status check to make sure plans are in place to reduce the risk of surgical fires and remind ourselves of the factors that contribute.
As one of the nation’s oldest public health and safety awareness campaign, NFPW was established by President Calvin Coolidge in 1925. NFPW is observed each year to commemorate the Great Chicago Fire which began in October 1871.
Know Your Operating Room Surroundings
An ignition source, fuel source, and oxidizer must be present for a fire to start. Common ignition sources in an OR include electrosurgical units (ESUs), lasers, fiberoptic light sources and high-speed drills that can produce sparks.
Surgical drapes, towels, gowns, masks, alcohol-based skin preparation agents, and even a patient can be a fuel source for fires. Oxidizers include supplemental gases such as oxygen and nitrous oxide, but also room air.
Surgical team members need to actively manage each of these sources and have contingency plans if and when there is a fire.
In addition, The Joint Commission encourages health care organizations to help prevent surgical fires by:
- informing staff members, including surgeons and anesthesiologists, about the importance of controlling heat sources by following laser and ESU safety practices
- managing fuels by allowing sufficient time for patient prep
- establishing guidelines for minimizing oxygen concentration under the drapes
- developing, implementing and testing procedures to ensure appropriate response by all members of the surgical team to fires in the OR
reporting any instances of surgical fires to The Joint Commission, ECRI Institute, U.S. Food and Drug Administration and state agencies, among others as a means of raising awareness and ultimately preventing the occurrence of future fires