Prevention Efforts Remain Necessary as Surgical Fires Decrease Statewide


​Oral anticoagulants, norovirus infections, advance directives, and more in the June 2018 Pennsylvania Patient Safety Advisory

Harrisburg, Pa., June 25, 2018 — The Authority's June 2018 Advisory highlights a statewide decrease in surgical fire events. However, experts stress that continual prevention efforts are key to this declining trend.

"Surgical fires in the operating room, while uncommon, can lead to devastating outcomes," said Dr. Ellen S. Deutsch, medical director for the Pennsylvania Patient Safety Authority. "While our analysis revealed a downward trend, it also revealed that patients and OR team members remain at risk in the absence of appropriate event precautions."  

From July 2011 through June 2016, 28 surgical fire events were reported to the Authority. These events were defined as fires on the operating field and equated to 5.6 fires per year in Pennsylvania. This represents a decline from the 10 fires per year reported in the Authority's 2012 analysis and represents a 44.0% reduction since 2011.

Of the 28 reports identified, patient harm was reported in 15 reports (54%) and no harm to patients or staff was reported in the remaining 13 (46%). 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 events.

The ignition source was named in 26 of the 28 reports, with the leading source identified as an electrosurgical unit (e.g., "Bovie") (n=22 or 79%), followed by a battery-powered cautery unit (n=2 or 7%), and a laser (n=2 or 7%). The role of oxygen was mentioned in 14 reports (50%). Nitrous oxide was not mentioned as an oxidizing agent in any reports.

"Surgical fires are completely preventable," said Deutsch. "Established prevention measures and ongoing education initiatives support the decrease Pennsylvania is seeing in surgical fire events, but that should not translate into a decrease in prevention efforts."

In the Authority's June 2018 Pennsylvania Patient Safety Advisory article, "Surgical Fires: Decreasing Incidence Relies on Continued Prevention Efforts," the Authority emphasizes the importance of sustaining prevention efforts for surgical fires and offers response and prevention resources for healthcare facility staff. Accompanying this article is a visual abstract explaining the downward trend of incidents statewide and highlighting vulnerable areas of harm for both patients and providers; and a Patient Safety Topic: Surgical Fires, hosting a collection of additional resources.  

Download the full article.

Also published in this Advisory:

  • Identifying Patient Harm from Direct Oral Anticoagulants
    Employing standard protocols to guide therapy, reviewing baseline patient information, including patient weight (in metric units) and laboratory test results such as renal and liver function, and considering the therapeutic indication can aid selection of an appropriate anticoagulant medication for patients.

For more information about the Authority, patient safety topics, Advisory articles, and safety tips for patients, please visit patientsafety.pa.gov.

The Authority's mission is to improve the quality of healthcare in Pennsylvania by collecting and analyzing patient safety information, developing solutions to patient safety issues, and sharing this information through education and collaboration. Its vision is safe healthcare for all patients.

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