Lessons Learned

Surgical Fires: Lessons Learned from the CHPSO Database

According to the Food and Drug Administration (FDA), there are between 550 and 650 surgical fires in the United States every year. These types of fires can result in catastrophic consequences including severe burns, permanent disfigurement and even death. Surgical fires are an example of an operating room (OR) fire. The American Society of Anesthesia defines OR fires and surgical fires as follows:

  • Operating Room fires are fires that occur on or near a patient under anesthesia care
  • Surgical fires are a type of OR fires that occur on or ina patient
  • Airway fires are surgical fires occurring in the patient’s airway, possibly involving the breathing circuit

Surgical fires are a risk any time all three sides of the fire triangle are present. The fire triangle consists of an oxidizer, an ignition source and a fuel source. The presence of an oxidizer-enriched environment increases the probability of a surgical fire. Examples of oxidizers in a surgical or procedural environment include oxygen and nitrous oxide. Ignition sources in a procedural environment are plentiful, with electrocautery devices most commonly associated with surgical fires.

Like ignition sources, fuel sources are also abundant in surgical and procedural areas. Examples include alcohol-based skin preps, drapes, gowns, endotracheal tubes, masks and packaging materials. The patient’s hair may also become a fuel source in some circumstances.

The presence of all three of these elements is a common occurrence during many surgical and invasive procedures. Operating room and procedural area staff must be vigilant and take all appropriate steps to prevent surgical fires and respond to one should preventative efforts prove unsuccessful. 

The prevention of surgical fires begins with a standardized risk assessment process. The risk assessment process should be applied to all surgical or invasive procedures. Both the Association of periOperative Registered Nurses (AORN) and the American Society of Anesthesiologists (ASA) offer tools and guidelines to support the implementation and adoption of standardized fire risk assessments. These resource can be utilized to guide in the development of standardized policies, procedures and check-lists related to the prevention and management of surgical fires.

It is also helpful to review cases of surgical fires and surgical fire near misses to identify opportunities for improvement and lessons learned. In a recent analysis, CHPSO reviewed more than 50 safety events related to surgical fires. A common theme among the opportunities for improvement was that of unsafe practices associated with the use of alcohol-based prep. Nearly all of the cases related to alcohol-based prep involved staff or surgeons not following established policies for dry time and/or disposal of materials soaked in prep. This poses a significant risk as pooling of liquid, alcohol based preps can generate highly flammable vapors underneath the surgical drapes. In some of these reports, staff were trying to stop the unsafe practice prior to the start, but were unsuccessful. Organizations should work to ensure that everyone involved is following the appropriate guidelines to minimize the likelihood of preventable patient harm related to surgical fires. To be maximally effective, any policies and /or procedures related to surgical fires should make it clear that any member of the team can speak up if they see an impending deviation in practice. Facilities may want to consider adopting approaches such as “Stop-The-Line, an approach borrowed from the auto manufacturing industry to empower all employees to shut down the production line should that individual suspect a safety concern.

Resources and References

Anesthesia Patient Safety Foundation: Prevention and Management of Operating Room Fires Video. Available here.

Apfelbaum, J. L., Caplan, R. A., Barker, S. J., Connis, R. T., Cowles, C., Ehrenwerth, J., … & Wolf, G. L. (2013). Practice Advisory for the Prevention and Management of Operating Room FiresAn Updated Report by the American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology: The Journal of the American Society of Anesthesiologists, 118(2), 271-290. Available here.

Mehta, S. P., Bhananker, S. M., Posner, K. L., & Domino, K. B. (2013). Operating Room Fires: A Closed Claims Analysis. Anesthesiology: The Journal of the American Society of Anesthesiologists, 118(5), 1133-1139. Available here.