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Surgical Fire Prevention

Surgical FireSurgical fires, though rare, can have devastating consequences for patients, staff, and the healthcare facility as a whole. It’s important to know how such fires can be prevented—and how to handle them if they occur.

Surgical fires that ignite in or around a patient during surgery continue to be a real danger, and are especially devastating if open oxygen sources are present during surgery of the head, face, neck, and upper chest.

Fortunately, surgical fires are rare: They occur in only an extremely small percentage of the approximately 65 million surgical cases each year. Extrapolating from data published by the Pennsylvania Patient Safety Authority in 2012, we estimate that 200 to 240 fires occur nationally each year, making the frequency of their occurrence comparable to that of other surgical mishaps (e.g., wrong-site surgery or retained instruments). 

Through awareness of the hazards—and with an emphasis on following safe practices—virtually all surgical fires can be prevented.

Surgical fire prevention downloadable posters

  • Surgical Fire Prevention (PDF)
  • Emergency Procedure Extinguishing a Surgical Fire (PDF)

Surgical fire resources​

  • Accident Investigation brochure (PDF)​
  • Extended Surgical Fires bibliography (PDF)
  • Surgical Fire Posters for $100 (Purchase 10 for $100)
  • Surgical Fire Prevention, Health Devices, October 2009 (view)
  • Oxygen Enriched Burning​ (video)

Fire extinguisher recommendations for operating rooms
ECRI Institute has recommended carbon dioxide (CO2) extinguishers for use in the OR for more than twenty years. This recommendation is supported by the Anesthesia Patient Safety Foundation (APSF) and the American Society of Anesthesiologists (ASA). The recommendation has also been published in the June 2006 issue of AORN Journal from the Association of peri-Operative Registered Nurses.

  • ECRI Institute Recommendations for Operating Room Fire Extinguishers, Health Devices, 10/2009 (PDF)
  • Selecting Fire Extinguishers for the Operating Room, Health Devices, 2/2009 (PDF)
  • Water-Mist Fire Extinguishers for Use in the OR, Health Devices Alerts, 9/29/2010 (PDF)
In the news
  • Tips for Compliance: Preventing Surgical Fires, The Joint Commission, 3/20/2013 (article)
  • Hospitals Still Feel the Heat of Fire Risks, Modern Healthcare, 12/19/2011 (article)
  • Fire Erupts on Woman’s Face During Routine Surgery, ABC News, 12/1/2011 (article)
  • Pennsylvania Biomedical Engineer is World's Expert on Medical Accidents, The Philadelphia Inquirer, 7/4/2011 (article)
  • Burn Victim Hopes her Story Calls Attention to Dangers of Surgical Fires, The Plain Dealer, 5/25/2010 (article)

Make sure your facility is aware of surgical fire prevention
ECRI Institute can provide you with new clinical guidelines on surgical fire prevention. For ordering and product information, please contact us, e-mail your request to Client Management Services, or call us at (610) 825-6000, ext. 5891.

Free surgical fire video
A new 18-minute video, produced by ECRI Institute for the Anesthesiology Patient Safety Foundation, Prevention and Management of Operating Room Fires, is an important educational resource for everyone who works in the OR during surgery. View the video or order a free DVD.  

Other resources you may be interested in

  • INsight™ (view)
      • Web-Based Risk Assessment for General Surgery (view)
      • Risk Assessment for Anesthesiology (PDF