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Publication Type: Patient Sasfety Advisory
Single or Multiple Incident: Multiple
Date: 6/1/2018 12:00:00 AM
This alert discusses the decreased incidence of surgical fires, incidence of harm, site and source of fire, contributing factors and some risk mitigation strategies. An updated report on the incidence of fires in the operating field involving flaming combustion resulting from a combination of heat, oxygen, and fuel identified twenty-eight events from July 2011 through June 2016, equating to 5.6 fires per year in Pennsylvania. That incidence is down from the 10 fires per year found in the 2012 analysis and represents a 44.0% reduction since 2011 and a reduction in the patient risk of surgical fires of 71% since 2004. One-half of the reported events indicated some degree of harm to the patient. The source of ignition was identified in 26 reports: an electrosurgical unit (e.g., "Bovie") in 22 reports (79% of 28 reports), a battery-powered cautery unit in two reports (7%), and a laser in two reports (7%). The operative sites of the head, neck, and upper chest constituted about two-thirds of the locations that were mentioned; oxygen-enriched atmospheres continue to be a major contributing factor to these incidents (70% incidence). Surgical fires with devastating consequences remain a significant risk. Facilities should consider using the Fire Risk Assessment Score and adhere to the recommendations of the American Society of Anesthesiologists Task Force on Operating Room Fires, the Anesthesia Patient Safety Foundation, and those of ECRI Institute. The alert provides a detailed list of strategies to prevent latex related patient safety incidents as well as a list of resources for surgical fire prevention and education.

Additional Details

Device:
electrosurgical active electrodes (e.g., Bovie units), bipolar electrodes, lasers, fiberoptic light cord, surgical lights, endotracheal tube, bronchoscope, laryngeal mask, battery powered cautery unit, electrosurgical active cable, nasal cannula, mask, carbon dioxide fire extinguisher
Medication/Gas/Fluid:
alcohol-based skin preparation, skin barrier ointment , oxygen, petroleum ether, sterile water, saline, anesthetic agents
Medication/IV List:
anesthetic agents, general, inhaled and IV

Environment / Equipment
  1. Electrosurgical active electrodes should be activated only when the tip is visible to the surgeon and should be holstered or removed from the sterile field when not in active use.
  2. Bipolar electrodes could also be used in conditions of high oxygen concentration at the target tissue.
  3. Water or saline for dousing a fire should also be available on the surgical field.
  4. A 5-pound carbon dioxide fire extinguisher should be available in the OR.
Rules / Policies / Procedures
  1. The scrub technician can help ensure meticulous application of alcohol-containing skin prepping solutions and confirm that they are dry before the application of surgical towels and drapes.
  2. Not incising the oxygen-filled trachea with an electrosurgical unit in the first place.
  3. The most important practice for managing the risk of a surgical fire is to minimize the use of supplemental oxygen to the level needed for adequate arterial oxygen saturation and to minimize the free flow of supplemental oxygen through a controlled airway, such as an endotracheal tube or laryngeal mask.
  4. There are defined exceptions where supplemental oxygen delivery may be required via an open source on the face, such as when a patient needs to speak during the surgery. For such cases, starting with an administered concentration of oxygen at 30% and using occlusive draping techniques can minimize the risks of dangerously high concentrations of oxygen being trapped under the drapes.
  5. Moistening sponges before use can minimize the risk of setting a sponge on fire.

Surgical Fires: Decreasing Incidence Relies on Continued Prevention Efforts