Surgical Fires: Education Necessary to Address More Than 100 Fires Annually

October 1, 2003 | Health System Risk Management


An infant was brought by ambulance personnel to a neonatal intensive care unit (NICU) for initiation of extracorporeal membrane oxygenation. The patient had been receiving six liters per minute of 100% oxygen (O2) from an O2 cylinder through a bag mask while in the ambulance and during transport to the NICU; upon reaching the unit, the patient was connected to a wall O2 outlet with the same bag mask. The patient was then placed in a warming unit, connected to jet ventilation, and draped for surgery. The O2 was left flowing through the discarded bag mask, which was left in the warming unit. The combined jet ventilation and wall-supplied O2 enriched the underdrape space and flowed up through the drape fenestration. An electrosurgical pencil was used at the beginning of the procedure and again about 10 minutes into the surgery. The initial use of the pencil left some desiccated blood on the probe tip; at the second use, the blood vaporized, mixed with the O2, and burst into flame under the drapes. This flare of tissue vapor ignited nearby towels and body hair, causing the fire to spread by surface-fiber flame propagation to the bag mask and throughout the warming unit. The drapes were pulled away, and bottled saline solution was used to douse the fire. The infant sustained second- and third-degree burns to about 30% of the body.

Surgical fires—fires like the one described above that occur on or in a surgical patient—happen only rarely, but their consequences can be devastating. They can kill or seriously injure patients, injure surgical staff, and damage critical equipment. The risk of surgical fires is present whenever and wherever surgery is performed, whether in an operating room (OR), a physician office, or an outpatient clinic.

According to Mark Bruley, ECRI's vice president for accident and forensic investigation, ECRI is alerted to an average of one to two surgical fires per week and conducts field investigations of about one surgical fire per month—and has done so for more than 20 years. Based on these investigations, published figures, and searches of the U.S. Food and Drug Administration's (FDA) medical device reporting databases, ECRI estimates that 100 or more surgical fires occur in the United States each year.

"That is probably at least as many, if not more, than the number of wrong-site surgeries occurring in the U.S. each year and is deserving of at least similar levels of attention," he says.

Some of that attention is already here. In June, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert on surgical fires, calling on healthcare organizations to educate their surgical staffs about fire risks and how to prevent them. The Alert cited recommendations from ECRI--included elsewhere in this article--on fire prevention steps and encouraged healthcare organizations to...

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