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.
Over the most recent four years in the study for which data was available, the rate of surgical fires varied from 0.63 per 100,000 operations (1 per 157,545 operations) in the academic year 2007-2008 to 0.32 per 100,000 operations (1 per 309,305 operations) in the academic year 2010-2011. One-third of the reported events indicated harm to the patient. Risk to providers, rather than patients, was cited in 6% of reports.
Figure 1. Trends in Surgical Field Fires
Fires require three elements:
An ignition source, such as an electrosurgical unit active electrode.
Oxidizers, such as oxygen, room air, N2O, or medical compressed air.
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
Source: ECRI. Reprinted with permission.
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.