SURGERY
Why aren’t surgical fires classed as a Never Event?
Nigel Roberts examines the evidence around the incidence of surgical fires, as well as current guidance to prevent associated harm. He considers whether surgical fires should be classed as a ‘Never Event’ and whether mitigating steps should be incorporated into the WHO surgical safety checklist.
The research on the current three intra- operative ‘Never Events’ has bought to light another potential intra-operative ‘Never Event’ for discussion – surgical fires. ‘Never Events’ are defined as ‘Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers’.1 Early research by Bruley2
concluded that
‘surgical fires are a preventable hazard’, five years prior to the publication of the World Health Organization’s (WHO) surgical safety checklist. So why was the decision made not to class a surgical fire as a ‘Never Event’? Research suggests that the first recorded surgical fire, occurring on a patient as a result of the use of anaesthetic gases, goes as back as far as 1850 – when ether caught fire during facial surgery.3,4
However, surgical
fires remain a significant safety issue today. Bruley2
wrote that ‘the prevention of
surgical fires requires understanding the risks and effective communication between surgical, anaesthesia and operating nursing staff. Preventative measures exist but have yet to diffuse across professional boundaries’.
This statement was prior to the launch of the WHO surgical safety checklist, and yet the literature still states that non-technical skills, such as communication, must be improved if the NHS and global health providers are to limit the number of ‘Never Events’. Craig et al5
(cited in Oak et al)6 ,
suggested that communication errors are the most common cause of adverse events. Keeley7
has categorised surgical fires
as either ‘airway’ or ‘non-airway’. Citing figures, from Overbey, Townsend and Chapman,8
she highlighted that there were 294 injuries and fatalities, as a result of surgical fires in the US, between 1994 and 2013 – while figures from Retzlaff9
JANUARY 2023
suggested that an estimated 550-650 fires occur annually in the US. She added that, in the UK, the National Reporting and Learning System (NRLS) database in England and Wales identified thirty-seven reported surgical fires between January 2012 and December 2018,7 Resolution10
while evidence from NHS reported that £13.9 million has
been paid out in damages and legal costs for 459 cases relating to clinical negligence caused by surgical burns.7
In 2019, the National Institute for Health and Care Excellence (NICE)11
identified the
pooling of flammable skin antiseptic as a cause of surgical fire (NG125). However, in 1998 and 2003, the Medical Devices
Agency issued alerts around surgical fires being caused by flammable prepping agents and high intensity light sources. Therefore, the question arises, what has changed in nearly twenty years?
et al13
In the 1990s, De Richemond12 and Greco et al14
, Reyes all stated that
the most common sites for a surgical fire are head and neck surgery, tracheal tube, tracheostomy, laser or electrosurgery ignited fires in the trachea or bronchus, and fires in the oropharyngeal cavity during tonsillectomy.
Over twenty years later, research by Bruley et al15 again concluded that the face, scalp, neck and chest are the most common
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