Patient Safety Topics
Fires, Surgical

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

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  

Figure 1. Trends in Surgical Field Fires    

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:
Clarke JR, Bruley ME. Surgical fires: trends associated with prevention efforts. Pa Patient Saf Advis 2012 Dec.
Electrosurgical units and the risk of surgical fires. PA PSRS Patient Saf Advis 2004 Sep.

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.

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



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