SURGERY


areas of surgical fires. Smith16


found that


devastating patient injuries including death have been reported.


In 2022, the Association for Perioperative


Practice (AfPP) published a dedicated section in the 5th edition of Standards and Recommendations for Safe Perioperative Practice for the risk management of fire prevention.17


The Fire Triangle


The ‘fire triangle’ has been developed for common causes in the operating room, which includes the three components essential to creating a fire and examples of common sources of each.18


(See Fig.1) The topic of surgical fires was debated in


Westminster on the 16 December 2021. It was put forward following a report published by the Surgical Fires Expert Working Group (EWG) in September 2020 (‘A case for the prevention and management of surgical fires in the UK.’)19,20 However, the MP for Patient Safety and


Primary Care, at that time, stated: “Surgical fires are not [classified as] a never event at the moment because there are no clear guidelines that staff can follow that can absolutely rule out any particular fire from happening. That is the crux of the matter. Fires should absolutely be preventable, and we should learn the lessons when a surgical fire takes place, but we do not have the guidelines to be able to say to staff what has to be followed to absolutely prevent a fire from happening in the first place.” As part of the report, AfPP surveyed 7,000 members, which resulted in 50% of members reporting witnessing a surgical fire.21


The Surgical Fires Expert Group (2020) found that, between 2010 and 2018, there were a total of ninety-six recorded surgical fire incidents declared by NHS England Acute Trusts and Wales Health Boards, but a search of the National Reporting and Learning System (NRLS) between January 2012 and December 2018 only identified thirty-seven reports of


Year


2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016


Number of Surgical Fires


14 9


11 11 7


12 6 8 6 6 6 2


Figure 1.


surgical fires. Of the thirty-seven reported surgical fires, 8% led to severe harm, 22% moderate harm, 8% no harm and 52% resulted in some degree of harm.4


This


highlights that much needed work is still required to address effective reporting of incidents.


The Bruley et al (2018)15 study in the


United States, which reported the rates of fire (see table 1) and what caught fire (see table 2), suggested that the decline was due to the efforts aligned with recent initiatives by a variety of medical professional societies and healthcare organisations, but warned that – although in decline – surgical fires remain a significant patient safety hazard. To conclude, surgical fires have declined over the years, due to advances in anaesthesia, as highly volatile gases – such as cyclopropane – are no longer used. Vogel22


suggests that recognition,


separation and management of the different components of the fire triad are therefore


Number of Patients


1,549,082 1,572,611 1,555,186 1,683,170 1,727,387 1,757,928 1,805,835 1,874,589 1,836,821 1,837,449 1,830,534 1,834,394


Rate of Surgical Fires per 100,000 Patients


0.9


0.57 0.71 0.65 0.41 0.68 0.33 0.43 0.33 0.33 0.33 0.11


Table one - Rates of fire per 100,00 patients undergoing operating room procedures. 50 l WWW.CLINICALSERVICESJOURNAL.COM


essential to reduce their incidence. Darouiche et al23


suggest that surgical


alcohol-based skin preparation should be avoided where possible – however, the risk must be balanced against evidence-based practice guidance surrounding the use of the alcohol-based skin preparation and its association with the lowest incidence of surgical site infections. Day et al24


conclude that there is


evidence to indicate that alcohol-based skin preparation should be avoided in unshaved dense hair-bearing areas on the head and face. Bruley2 and Kezze et al26


all comment that the


other contributory factors to a surgical fire include: a lack of education, poor team communication, other human factors, equipment design and the absence of evidence-based practice. Bruley27


and Kezze et al26


, Lampotang et al25


suggest that


education should emphasise the increased risk created by an oxidiser-enriched environment and therefore what constitutes a high-risk procedure. Blaquez and Thorn28 define a ‘high-risk environment’ as ear, nose and throat surgery, maxillofacial surgery, head or neck surgery, laser surgery, laparoscopic surgery and mediastinal surgery. A study by Tola et al29


States has also shown that education can help improve knowledge and awareness of surgical fire among perioperative staff. Finally, Parremore30


suggests that


something should be incorporated into the WHO surgical safety checklist at the ‘Time- out’ step to ensure any risk of fire is limited. This would seem a logical step forward – not just for the NHS, but global healthcare providers, to ensure theatre staff are mitigating patient harm the best they can. CSJ


JANUARY 2023


in the United


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