Surgical Fires

June 1, 2016 | Health System Risk Management


Surgical fires—fires that occur on or in a surgical patient—rarely happen, but their consequences can be devastating. Patients can be killed, staff can be injured, critical equipment can be damaged, and lawsuits stemming from surgical fires can lead to substantial awards to plaintiffs. Even a facility's status as a Medicare and Medicaid provider can be jeopardized if the organization fails to prevent surgical fires. Fines have also been levied against hospitals that experienced a surgical fire and had failed to develop and maintain surgical fire prevention policies and procedures. (Scott-Goforth)

The risk of surgical fires is virtually always present whenever and wherever surgery is performed, whether in an OR, a physician office, or an outpatient clinic. In fact, ECRI's Accident and Forensic Investigation Group receives, on average, one or two reports of surgical fires each week, although the overall incidence is much higher.

Between July 1, 2004, and June 30, 2011, the Pennsylvania Patient Safety Authority, which oversees a state-mandated event and near-miss reporting system, received 70 reports of surgical fires in the state. The Authority found that the rate of surgical fires for July 1, 2010, through June 30, 2011, was 1 for every 300,973 surgical patients, a drop from a high of 1 per 110,649 surgical patients in the year between July 1, 2004, and June 30, 2005. The group states that while the decrease in rate was "noticeable," it was not statistically significant. The Authority also calculated the rate of surgical fires per operation in the state; however, these data were available only for the period between July 1, 2007, and June 30, 2011. For this data set, the rate of surgical fire ranged from 1 in 157,545 operations between July 1, 2007, and June 30, 2008, to 1 in 309,305 operations between July 1, 2010, and June 30, 2011. (Clarke and Bruley)

Surgical fires occur in only a small share of the estimated 65 million inpatient and outpatient surgical procedures performed each year in U.S. healthcare facilities, and ECRI estimates that 95% of surgical fires result in no injury. However, in ECRI's experience, about 20 to 30 fires occur each year that cause disfiguring or disabling injuries. And one or two—typically surgical fires occurring in the airway—are fatal. (ECRI "New")

Preventing and Fighting Airway Fires

ECRI has published numerous reports on surgical fire prevention based on its investigations of surgical fires and research on their causes. ECRI's most recent recommendations on this evolving patient safety issue were published in October 2009 in ECRI's Health Devices (ECRI "New"). The report provides recommendations developed in conjunction with the Anesthesia Patient Safety Foundation (APSF) for delivering oxygen during surgery; these recommendations are directed at discontinuing the traditional practice of unquestioned open delivery of...

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