Prevent Surgical Fires Reduce risk with understanding BY ROBERT KURTZ


lthough rare, surgical fires con- tinue to occur in health care

facilities. Their prevention must be an ongoing area of focus for ASCs, says Mark Bruley, vice president of acci- dent and forensic investigation for ECRI Institute, a Plymouth Meeting, Pennsylvania-based organization that researches approaches to improving patient care. “Although the number of fires is decreasing, based on recent state-based incident reporting system data analyses, there should never be a surgical fire,” he says. “Virtually all are preventable.” According to a Pennsylvania Patient Safety Authority analysis, 70 surgical fires were reported in the state between July 1, 2004, and June 30, 2011. Over the past four years for which data was available, the rate of surgical fires var- ied 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 per- cent of reports.

According to its website, ECRI Institute estimates around 200–240 surgical fires occur annually in the US, about the same number as other sur- gical mishaps, such as wrong-site sur- gery or retained instruments. To prevent surgical fires, ASCs must understand why they happen, Bruley says. The most common rea- son is the unquestioned use of an open source of oxygen on a patient’s face during monitored anesthesia care. “The failure to assess patient need

for pure oxygen, as opposed to using air, delivered on the face during sur- gery, continues to be the major con- tributing cause,” he says. “In a major-

ing is completed. That puts the respon- sibility on the circulator to keep every- one on hold—even the surgeon—until it is safe to begin the procedure.” To help ensure adequate drying time has passed, Hoeft-Hoffman prefers to use a timer rather than look at a clock. “If you look at a clock, the interpretation of how much time has passed can vary. But if you set a timer, there is no debate.” To further improve staff training

There needs to be buy-in by senior management to the reality that surgical fires are pre- ventable, and for them to support education and implementation of preventive policies and procedures at their facility.”

— Mark Bruley ECRI Institute

ity of surgical fire cases, it is all about the oxygen being delivered on the face. A very minor percentage of other cases are alcohol vapor fires.” Tracy Hoeft-Hoffman, RN, CASC, administrator of Heartland Surgery Center in Kearney, Nebraska, says her ASC provides annual staff education regarding OR fire prevention. One com- ponent focuses on ensuring adequate dry time for an alcohol-based prep. “The risk of a fire increases if you start a case and use cautery before allowing the alcohol prep to dry,” she says. “Sur- geons are anxious to get going on their case, but they should not start until dry-


on surgical fires, Hoeft-Hoffman says she is considering bringing in outside expertise. “I worked at another orga- nization that brought someone in who simulated fires in an OR setting. This gave staff the opportunity to actually put out a fire. The consultant walked through that experience and also reviewed the quickest routes out of the OR in the event of a fire. I am looking into bringing that experience here.” Bruley says it is imperative that ASC leadership take the risk of surgical fires seriously. “The time has come where a top-down emphasis is needed. There needs to be buy-in by senior manage- ment to the reality that surgical fires are preventable, and for them to support edu- cation and implementation of preventive policies and procedures at their facility.” He says surgical fire prevention edu- cation sometimes takes second fiddle to other perioperative hazards. “Given the potentially devastating or fatal outcomes of a surgical fire, reeduca- tion on an annual basis is worthwhile. If OR staff—including all physicians and anesthesia professionals—were required to view the ‘Prevention and Management of Operating Room Fires’ video (go to fire-safety/) from the Anesthesia Patient Safety Foundation, that should refresh them sufficiently about the preven- tive measures for minimizing the vast majority of surgical fires.”

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