National Patient Safety Goals

Preventing Monica L. Lypson, M.D.

Sara Stephens, M.A., P.H.R.
Lisa Colletti, M.D.
Surgical Fires: Department Editors: Marcia M. Piotrowski, R.N., M.S.,
Michael Cohen, R.Ph., M.S., Sc.D., Jill Mercier, R.N., M.S.,
Who Needs to Sanjay Saint, M.D., M.P.H., Amy Steinbinder, R.N., Ph.D.
Readers may submit National Patient Safety Goals inquiries

be Educated? and submissions to Steven Berman ([email protected])

and Marcia Piotrowski ([email protected]).

S
urgical fires have frequently been portrayed in the
movies and on television. Nevertheless, the risk of Article-at-a-Glance
a surgical fire is exceedingly low and therefore
could potentially be eliminated with proper sustainable Background and Case Study: Surgical fires are rare but
interventions, including staff preparation and education. preventable. During facial surgery for a 68-year-old man,
In June 2003, the Joint Commission on Accreditation of a fire broke out, resulting in first- and second-degree
Healthcare Organizations published a Sentinel Event Alert burns after a nasal cannula ignited in an oxygen-rich
on surgical fires.”1 In August 2005, the Joint Commission environment because of improper draping and tenting.
announced a new National Patient Safety Goal, “Reduce Discussion: Operating room (OR) fires can be pre-
the risk of surgical fires,”2 for the Ambulatory and Office- vented if any component of the “fire triangle”—fuels,
Based Surgery program areas, as follows: ignition sources, and oxidizers—is reduced or elimi-
Goal 11: Requirement 11A. Educate staff, including nated. The use of supplemental oxygen in the OR via
operating licensed independent practitioners and anes- nasal cannulae, nebulizers, and oxygen cylinders must
thesia providers, on how to control heat sources and always considered a potential source of fire. Deficits in
manage fuels and establish guidelines to minimize oxy- knowledge among the surgical team with respect to the
gen concentration under drapes. prevention and management of surgical fires were
Before the sentinel event alert, all data regarding surgi- apparent. A plan was put into place to improve fire
cal fires were anecdotal and were collected via multiple safety education, entailing an educational program that
agencies, with no single reporting mechanism in place. In is included in intern and resident orientation. Surgical
2003, the National Fire Protection Association and ECRI fire safety training was also put into place for anesthe-
(formally, Emergency Care Research Institute), on the sia and surgical faculty. The anesthesia preoperative
basis of the U.S. Food and Drug Administration’s (FDA) evaluation was modified to include an assessment of
reporting database, estimated that between 50 and 100 the patients’ ability to tolerate short periods without
surgical fires occur each year in the United States.3 oxygen. Posters and signs are now displayed in each
Patients are seriously injured or are involved in litigation OR suite. A complete policy review and update ensures
in about 10 to 20 of those cases reported.4 that at least two fire drills are performed annually.
Conclusion: Surgical fires can usually be prevented by
Case Study educating staff about risk and prevention strategies. Such
A 68-year-old man was scheduled for ambulatory surgery. education should be part of all undergraduate medical,
His medical history was significant for squamous cell nursing, and other allied health profession education.

522
September 2005 Volume 31 Number 9
Copyright 2005 Joint Commission on Accreditation of Healthcare Organizations
carcinoma of the right cheek, with previous resections in overnight observation. Ophthalmology determined that
1991 and 1993. The patient presented again in 2003 with the patient’s vision had not changed and that there was
skin changes, and biopsies demonstrated recurrent dis- no evidence of ocular injury from the fire.
ease. An otolaryngologist recommended that he undergo Following the events in the OR, the patient and his
a wide local excision of the right preauricular and right sister were immediately informed about the complica-
cheek lesions. tions and provided a detailed explanation. The nurse
After the patient presented at the ambulatory surgery entered an incident report into the computer system,
operating room (OR) for the procedure, he was prepped including the circumstances of the events. A thorough
and draped for the facial excision. The surgical team was review involving the chief of staff, chief of surgery, and
made up of three members of the nursing staff, one chief of anesthesiology was conducted, and the case
attending physician, two surgical residents, one anesthe- findings were submitted to the safety case management
siologist, and one nurse anesthetist. The monitored anes- committee for further assessment.5
thesia was induced, and four liters of oxygen were given Biomedical engineering and the surgical staff inspect-
per nasal cannula during the procedure. The surgeon ed the electrocautery unit that was used in the incident.
used an elliptical incision around the preauricular The dispersive electrode was placed on clean dry skin
skin lesion. The long axis of the ellipse was parallel over a well-perfused muscle mass and close to the oper-
to the preauricular skin crease. The ellipse of tissue was ative site. During the procedure, the active electrode was
removed and oriented; no margins were obtained. Flaps kept in the protective holster to prevent accidental acti-
were raised and the tissue was advanced and closed— vation. Review of this case indicated a high likelihood of
primarily using a 4-0 synthetic absorbable suture for the a draping problem, resulting in oxygen being trapped
subdermal layer and a 5-0 chromic suture for the skin. In under the drapes and subsequently igniting when the
addition to the wide excision, four separate punch biop- cautery unit was used.
sies were obtained of the suspicious skin lesions on the
right cheek. Discussion
A moderate amount of bleeding was encountered dur- The classic “fire triangle” is a concept that most
ing the punch biopsies, and an electrocautery device was individuals are exposed to in elementary school. All
used to cauterize the skin edges—igniting the nasal can- three elements—heat, fuel, and an oxidizer—must be
nula and surgical drapes surrounding the face. The sur- available to start a fire.3,6 When they come together in the
geon poured sterile water from the operative tables on right concentrations and conditions, there is a release of
the patient and the nasal cannula to extinguish the fire. energy and subsequent fire. OR fires can be prevented if
The nasal cannula and drapes were removed from the any component of the triangle is reduced or eliminated.
patient and thrown to the floor. The nasal cannula con- Different members of the surgical team are in control of
tinued to burn until anesthesia personnel turned the oxy- different elements, as follows:
gen off. Once the fire was extinguished, new instruments ■ The surgeon is often involved with the ignition, or
and drapes were obtained. The patient was redraped and heat sources, which include electrocautery units, lasers,
the procedure was completed. A thorough examination and other light sources
indicated first- and second-degree burns involving both ■ The nursing staff’s domain is typically the fuels, such
cheeks, as well as the right nasal vestibule. The burns as operative preparation solutions, drapes, dressings,
were cleaned and an antibiotic ointment was applied. In ointments, and equipment
the immediate postoperative period, the patient noted ■ Anesthesia usually controls the oxidizers, such as
normal vision but was also found to have some evidence compressed air, oxygen, and nitrous oxide
of chemosis, that is, excessive edema of the ocular Nevertheless, all members of the surgical team must
conjunctiva. In addition, some singeing of his left eye- be aware of these three factors and continually be vigi-
lashes and eyebrow were also noted. Given these intra- lant in their efforts to keep the three elements separate7
operative complications, the patient was admitted for and prevent fires.

523
September 2005 Volume 31 Number 9
Copyright 2005 Joint Commission on Accreditation of Healthcare Organizations
 The Fire Triangle including how to approach fires at the facility. The
Many of the materials commonly found in the OR, residents are also provided with a surgical fire
including cloth and paper drapes, body hair, tissue, and brochure (Figure 1, page 525–526). The educational
intestinal gases, can function as fuels for potential fires. program includes a 15-question multiple choice test to
In addition, endotracheal tubes, face masks, adhesives, ensure understanding of the topics presented.13 All
petroleum jelly, and liquid skin-cleaning preparations specialties are included in this program; other special-
have all been shown to be ignitable by such common OR ties commonly refer patients for ambulatory surgery,
utensils as elctrocautery.3,8 thereby enabling residents to provide patient educa-
The use of supplemental oxygen in the OR via nasal tion regarding the risks of surgical fires. This is espe-
cannulae, nebulizers, and oxygen cylinders must cially important for those patients who need oxygen
always considered a potential source of fire. Several supplementation.
authors have noted the dangers of oxygen supplemen- In summer 2004, a survey of 152 incoming interns
tation during facial surgery.9–11 Case reports and experi- indicated that 93 (61.2%) had never heard of or were not
mental reenactments have shown that oxygen-enriched aware of the risk of surgical fires. Eighty-seven percent
atmospheres exist beneath surgical drapes and that felt that following the educational program, they would
this contributes significantly to the potential fire hazard know how to prevent surgical fires.
in the OR.9,11,12 As stated earlier, this has been hypo- Surgical fire safety training was also put into place
thesized as the likely cause of the fire in our case. The for anesthesia and surgical faculty. The anesthesia pre-
use of the lowest possible oxygen concentration that operative evaluation was modified to include an assess-
ensures adequate oxygenation or the administration ment of the patients’ ability to tolerate short periods
of oxygen with nonflammable gases can reduce the without oxygen. If possible, during head and neck sur-
potential for fire.8 gery supplemental oxygen is turned off (or the flow min-
Finally, once there is an adequate source of fuel and imized) when using electrocautery. Posters and signs
oxygen, ignition must occur, which requires a sufficient (for example, ECRI’s “Only you can prevent surgical
energy source. Electrocautery and laser technology are fires”) are now displayed in each OR suite. A complete
commonly used in today’s ORs. These tools, which policy review and update ensure that at least two fire
supply intense heat concentrated in small areas, are drills are performed annually. The nursing staff visually
the most common ignition source in surgical fires, inspects the electrocautery units and ensure that the
accounting for 81% of all fires.1 Other potential fire cautery device is sheathed in its protective holster when
sources are defibrillators, argon beam coagulators, and not in use. When the patient is draped, every effort is
fiber optic lights.3 made to prevent “tenting” that could potentially allow
oxygen to accumulate beneath the drape. To eliminate
Prevention the risk of tenting in the presence of oxygen, sticky
While following up on the incident described in the drapes are routinely used if electrocautery is to be
Case Study, we found deficits in knowledge among the performed in the head and neck area. The surgical
surgical team with respect to the prevention and man- teams uses the “time-out” technique not only to assess
agement of surgical fires. This was most notable among for correct site intervention but also to monitor the use
the surgical residents; nonsurgical faculty and staff were of electrocautery units or lasers in the head and
not aware that surgical fires were a possibility. neck area.
A plan was put into place to improve fire safety Review of the fire triad is necessary to prevent surgi-
education, entailing an educational program that is cal fires (Figure 1), as is review of the actions to take
included in intern orientation. All incoming interns when a fire does occur. To meet this need, continual
and residents are educated and tested on aspects review of fire policies and fire drills that emphasize
of fire safety, including surgical fires. A training Rescue, Alert/Alarm, Contain, and Extinguish (RACE) is
station was established that provides video education, the foundation for an individual’s preparedness.4

524
September 2005 Volume 31 Number 9
Copyright 2005 Joint Commission on Accreditation of Healthcare Organizations
 Surgical Fires: Awareness, Prevention, and Response
Applicable for Surgeries or Invasive Procedures Done in a Physician’s Office,
Outpatient Clinic, Inpatient Room, or Operating Room

continued

525
September 2005 Volume 31 Number 9
Copyright 2005 Joint Commission on Accreditation of Healthcare Organizations
 Surgical Fires: Awareness, Prevention, and Response, continued

Figure 1. As is shown in the brochure, review of the fire triad is necessary to prevent surgical fires.

526
September 2005 Volume 31 Number 9
Copyright 2005 Joint Commission on Accreditation of Healthcare Organizations
Conclusion Patient Safety Goals should ensure that it receives the
As our experience and educational interventions demon- attention it deserves in education and practice. J
strate, surgical fires can usually be prevented by educating The authors thank the faculty, program directors, and administrators at
Ann Arbor VA Healthcare System (Safety Case Management Committee
staff regarding risk and prevention strategies. Yet because and Rudi Rabe, R.N.) and the University of Michigan Health System, who
surgical fires are so rare, few physicians are aware of the ensured the success of the educational assessment reported in this article.
risk, and even fewer trainees learn about them during their
medical education programs. They are rarely discussed in
Monica L. Lypson, M.D., is Associate Chief of
the medical literature, with the exception of peri-operative Staff/Ambulatory Care, Ann Arbor Veterans Administration
nursing and anesthesiology.3 Education on fire safety Healthcare System, and Assistant Dean of Graduate Medical
should be part of all undergraduate and graduate medical, Education, University of Michigan Medical School (UMMS),
nursing, and other allied health profession education.14,15 Department of Internal Medicine, Ann Arbor, Michigan. Sara
After all, the ultimate outcome for all health care profes- Stephens is Safety Education Specialist, Safety Management
Services, University of Michigan Hospitals and Health
sions is the safe and effective medical treatment for their
Centers. Lisa Colletti, M.D., is Professor of Surgery and
patients; improving fire safety translates into decreased Graduate Medical Education, UMMS. Please address corre-
morbidity and mortality for patients and staff.13 The addi- spondence to Monica L. Lypson, M.D., [email protected].
tion of surgical fire safety to the Joint Commission National

References
1. Joint Commission on Accreditation of Healthcare Organizations: 8. Podnos Y.D., Williams R.A.: Fires in the operating room. Bull Am Coll
Sentinel Event Alert 29. Preventing Surgical Fires, Jun. 24, 2003. Surg 82:14–17, Aug. 1997.
http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/ 9. Howard B.K., Leach J.L.: Prevention of flash fires during facial sur-
sea_29.htm (last accessed Jul. 15, 2005). gery performed under local anesthesia. Ann Otol Rhinol Laryngol
2. Joint Commission on Accreditation of Healthcare Organizations: The 106:248–251, Mar. 1997.
Joint Commission Announces the 2005 National Patient Safety Goal 10. Barker S.J., Polson J.S.: Fire in the operating room: A case report
Requirements. Jt Comm J Persp 24:1,3–10, Aug. 2004. and laboratory study. Anesth Analg 93:960–965, Oct. 2001.
3. A clinician’s guide to surgical fires: How they occur, how to prevent 11. Barnes A.M., Frantz R.A.: Do oxygen-enriched atmospheres exist
them, how to put them out. Health Devices 32:5–24, Jan. 2003; Erratum beneath surgical drapes and contribute to fire hazard potential in the
in: Health Devices 32:176, May 2003. operating room? AANA Journal 68:153–161, Apr. 2000.
4. Salmon L.: Fire in the OR: Prevention and Preparedness. AORN J 12. Greco R.J., et al.: Potential dangers of oxygen supplementation dur-
80:41–42, 44–48, 51–52, 54, Jul. 2004. ing facial surgery. Plast Reconstr Surg 95:978–984, May 1995.
5. Piotrowski M.M., Saint S., Hinshaw D.B.: The Safety Case 13. Lypson M.L. et al.: Assessing residents’ competencies at baseline:
Management Committee: Expanding the avenues for addressing Identifying the gaps. Acad Med 79:564–570, Jun. 2004.
patient safety. Jt Comm J Qual Improv 28:296–305, Jun. 2002. 14. American Association of Medical Colleges: Report V.:
6. Medical Device Safety Reports (MDSR): The Patient Is on Contemporary Issues in Medicine: Quality of Care. Medical School
Fire! A Surgical Fires Primer. Guidance 21:19–34, Jan. 1992 Objectives Project Aug. 2001. http://www.aamc.org/meded/msop/
http://www.mdsr.ecri.org/ summary/detail.aspx?doc_id=8197&q=fire msop5.pdf (last accessed Jul. 15, 2005).
(last accessed Jul. 15, 2005). 15. Accreditation Council of Graduate Medical Education: Outcome
7. Smith C.: Surgical fires-learn not to burn. AORN J 80:23–27, 29–31, Project. General Competencies, 1999. http://www.acgme.org/outcome/
33–34, 36, Jul. 2004. comp/compMin.asp (last accessed Jul. 15, 2005).

527
September 2005 Volume 31 Number 9
Copyright 2005 Joint Commission on Accreditation of Healthcare Organizations