Patient Safety Topics
:
Fires, Surgical
Overview

Fires on the operating field are rare events that should never happen, but do. They are dangerous not only to the patient but to the operating room (OR) team members as well. Surgical fires remain a significant enough risk to justify use of a Fire Risk Assessment Score and adherence to the recommendations of the American Society of Anesthesiologists Task Force on Operating Room Fires and those of the Anesthesia Patient Safety Foundation.

Key Data and Statistics

 In 2012, the Pennsylvania Patient Safety Authority published an analysis of surgical fires reported through its database for the primary purpose of determining whether surgical fires continued to be a problem. A panel of patient safety analysts identified surgical fires reported to the Authority between July 1, 2004, and June 30, 2011. Seventy reports met the analysts’ definition of fires on the operating field.

In 2018, the Authority published an update, including analysis of events reported from July 1, 2011, through June 30, 2016:

  • 28 reports met the same definition of fires on the operating field
  • 9,213,796 patients were reported to have undergone operating room (OR) procedures
  • 9,486,042 OR procedures were performed

The model suggests a 71% decrease in the patient risk of surgical fires from AY2005 through AY2016 (i.e., AY, academic year). The analysts noted that in AY2005, there was about one surgical fire per month in Pennsylvania, and, if the downward trend continues, the rate will be only one surgical fire per year in AY2032.

Figure 1.   

Incidence of Surgical Fires Improves in Pennsylvania  

Fires require three elements:

  1. An ignition source, such as an electrosurgical unit active electrode.
  2. Oxidizers, such as oxygen, room air, N2O, or medical compressed air.
  3. Fuel, such as hair, surgical drapes, face masks,  tracheal tubes, and other materials. Materials that don’t readily ignite and burn in room air (21% O2) will easily burn when the atmosphere is slightly enriched.

Figure 2. The Components of OR Fires

Figure 2. The Components of OR Fires

Source: ECRI. Reprinted with permission.

Excerpted from:
Bruley ME, Arnold TV, Finley E, Deutsch ES, Treadwell JR. Surgical fires: decreasing incidence relies on continued prevention efforts. Pa Patient Saf Advis 2018 Jun. http://patientsafety.pa.gov/ADVISORIES/Pages/201806_SurgicalFires.aspx.
Clarke JR, Bruley ME. Surgical fires: trends associated with prevention efforts. Pa Patient Saf Advis 2012 Dec. http://patientsafety.pa.gov/ADVISORIES/Pages/201212_130.aspx.
Electrosurgical units and the risk of surgical fires. PA PSRS Patient Saf Advis 2004 Sep. http://patientsafety.pa.gov/ADVISORIES/Pages/200409_09.aspx
 

Educational Tools

Airway Fires during Surgery
Airway surgeries that involve ignition sources to cut or coagulate tissue pose a significant and sometimes deadly risk of fire. This poster discusses ways to minimize and fight airway fires.

Multimedia
Update on Clinical Guidance for Surgical Fire Prevention and Management
Safety Tips for Patients

 

 

©2018 Pennsylvania Patient Safety Authority