By ECRI

Fires in the operating room are rare; but when they occur, they can be devastating for all involved. ECRI, in collaboration with the Anesthesia Patient Safety Foundation (APSF), has developed new posters outlining how surgical teams can minimize the risk of fire during surgery, and how they can mount a rapid and coordinated response should a fire occur.

Fires that ignite in or around a patient during surgery can cause severe and lasting damage. Patients can be killed or suffer serious harm, staff can be injured or traumatized, and critical equipment or infrastructure can be destroyed. The consequences can be especially serious if open oxygen sources are present during surgery of the head, face, neck, or region of the upper chest above the xiphoid process. Thus, it’s important to know how such fires can be prevented – and how to handle them if they occur.

New resources issued by the Joint Commission and by ECRI in collaboration with the Anesthesia Patient Safety Foundation (APSF) have prompted a renewed focus on this rare but critical hazard.

The Issue in Brief

The key to preventing surgical fires is to control the three elements of the “fire triangle”: A fire will occur when an oxidizer, an ignition source, and a fuel come together in the proper proportions and under the right conditions. Keeping the elements of the fire triangle from coming together in ways that could lead to a surgical fire requires that all surgical team members understand the risks and that they consistently follow practices that can minimize those risks.

“Every side of the fire triangle has a representative in the operating room,” explains Julie Miller, principal project engineer in ECRI’s Device Evaluation group. “So preventing fires requires that every team member understands how their actions can contribute to the conditions for a surgical fire.” Similarly, should a fire occur, “every team member needs to know their role in the response.”

Healthcare Incident Investigation

New: The Joint Commission’s Sentinel Event Alert

In October 2023, the Joint Commission issued an updated Sentinel Event Alert – “Updated Surgical Fire Prevention for the 21st Century” – to help health care organizations recommit to surgical fire prevention. As the organization states, “surgical fires continue to occur and represent a significant risk to patients and health care professionals.” (See: https://www.jointcommission.org/-/media/tjc/newsletters/sea-68-surgical-fire-prevention2-10-9-23-final.pdf.)

In its Sentinel Event Alert, the Joint Commission suggests the following actions to prevent surgical fires:

1. Conduct a time-out before each surgical and endoscopic procedure to assess (a) any fire risks associated with the supplies and equipment to be used, (b) the location of the operation on the patient, and (c) the presence of ignition sources, fuel, and oxygen in the environment.
2. Maintain the concentration of oxygen delivered to the patient at less than 30%, whenever possible.
3. Carefully manage electrosurgical devices, light sources and cables, surgical draping, and other risks during a procedure.
4. Provide training to operating room staff on how to avoid and manage fires and conduct fire drills, as stipulated in the Joint Commission standards.
5. Report all surgical fires into your facility’s incident reporting system.
6. Encourage education of all operating room personnel/team members about the risk of surgical fires.

New: Posters from ECRI and APSF

ECRI and APSF have developed the following posters to help reduce the risk of, and potential harm from, surgical fires. Readers are encouraged to download and print these posters and place them in their operating rooms:

“Surgical Fire Time-Out: Team Communication is Key” – Download from: https://ly.ecri.org/SurgicalFireTimeOut.

“Know Your Part When Responding to a Surgical Fire” – Download from: https://ly.ecri.org/SurgicalFireResponse.

To Learn More . . .

The posters referenced in this article can be downloaded free of charge using the links provided. For information about ECRI’s proactive surgical fire prevention assessment service or its on-site educational programs, visit https://ly.ecri.org/SurgicalFirePrevention_Services. In addition, members of ECRI’s Capital Guide, Device Evaluation, and associated programs can access the organization’s “Surgical Fire Prevention: The Essentials” web page – a collection of ECRI resources to help with fire prevention efforts. To learn more about membership, visit https://www.ecri.org/solutions/device-evaluations, or contact ECRI by telephone at (610) 825-6000, ext. 5891, or by e-mail at clientservices@ecri.org.