SURGERY


References 1 NHS Improvement (2021), Never Events list 2018, first published January 2018 (Last updated February 2021), https://www.england.nhs.uk/ wp-content/uploads/2020/11/2018-Never-Events- List-updated-February-2021.pdfm [Accessed 24 July 2022]


2 Bruley, M. E. (2004), Surgical Fires: perioperative communication is essential to prevent this rare but devastating complication. Qual Saf Health Care, 13, pp. 467-471 doi: 10.1136/qshc.2003.005819


3 Macdonald AG. A brief historical review of non- anaesthetic causes of fires and explosions in the operating room. Br J Anaesth. 1994 Dec;73(6):847- 56. doi: 10.1093/bja/73.6.847. PMID: 7880680.


4 Rodger, D. (2019), Surgical Fires: Still a burning issue in England and Wales, Journal of Perioperative Practice, https://journals. sagepub.com/action/authenticateSharedSP doi: 10.1177/1750458919861906 [Accessed 25 July 2022]


5 Craig R, Moxey L, Young D, Spenceley NS, Davidson MG. Strengthening handover communication in pediatric cardiac intensive care. Paediatr Anaesth. 2012;22:393–9. [PubMed] [Google Scholar]


6 Oak, S. N., Dave, N. M., Garasia, M. B., and Parelkar, S. V. (2015), ‘Surgical checklist application and its impact on patient safety in pediatric surgery’, Journal of Postgraduate Medicine, 61 (2), pp. 92-94. doi: 10.4103/0022-3859.150450.


7 Keeley, L (2020), Surgical fires must become ‘Never Event’, Clinical Services Journal, pp.18-20, https:// www.clinicalservicesjournal.com/story/33506/ surgical-fires-must-become-never-event, [Accessed 24th July 2022]


8 Overbey, DM; Townsend, NT; and Chapman BC. Surgical energy-based device injuries and fatalities reported to the Food and Drug Administration Journal of the American College of Surgeons. 221 (1) pp. 197-205.


9 Retzlaff K. Fighting fire with preparation. AORN Connections. October 2009.


10 NHS Resolution. Did you know? Preventing Surgical Burns, 2019 Oct


11 The National Institute for Health and Care Excellence (2019), https://www.nice.org.uk/ guidance/ng125 [Accessed 24 July 2022]


12 de Richemond AL, Bruley ME. Head and neck surgical fires. In: Eisele DW, ed. Complications in head and neck surgery. St Louis: Mosby-Year Book, 1993.


13 Reyes RJ, Smith AA, Mascaro JR, et al. Supplemental oxygen: ensuring its safe delivery during facial surgery. Plast Reconstr Surg 1995;95:924–8.


14 Greco RJ, Gonzalez R, Johnson P, et al. Potential dangers of oxygen supplementation during facial surgery. Plast Reconstr Surg 1995;95:978–84.


15 Bruley, M. E., Arnold, T. V., Finley, E., Deutsch, E. S., and Treadwell, J. R. (2018), Surgical fires: Decreasing incidence relies on continued prevention efforts, Pa Patient Saf Advis, 15 (2), pp. 1-12


16 Available at http://patientsafety.pa.gov/ ADVISORIES/Pages/201806_SurgicalFires.aspx.


17 Smith C. Surgical fires: learn not to burn [home study program]. AORN J 2004;80:24–40.


JANUARY 2023


Item


Hair, eyebrows or beard Sponge


Drape or Towel Eyelashes only


Flammable skin-barrier ointment Alcohol skin-based prep


Endotracheal tube or bronchoscope Adhesive


Bone Cement


Electrosurgical active cable Glove


Petroleum ether


Number of reports


7 6 5 4 3 2 2 1 1 1 1 1


Table two - Items that caught fire in the operating room (July 2011 – June 2016)


18 Association for Perioperative Practice (2022), Standards and recommendations for safe perioperative practice, Risk Management, Fire Prevention, p. 82-89.


19 Jones EL, Overbey DM, Chapman BC, Jones TS, Hilton SA, Moore JT, Robinson TN: Operating room fires and surgical skin preparation. J Am Coll Surg 2017; 225:160–5


20 A case for the prevention and management of surgical fires in the UK, Accessed at: https://www. afpp.org.uk/news/A_case_for_the_prevention_ and_management_of_surgical_fires


21 Association for Perioperative Practice (2021), AfPP Response to Westminster Debate on Preventing Surgical Fires in the NHS. https://www.afpp.org.uk/ news/response-westminster-debate-surgical-fires [Accessed 24th July 2022]


22 Accessed at: https://www.pslhub.org/ learn/patient-safety-in-health-and-care/ high-risk-areas/surgery/a-case-for-the- prevention-and-management-of-surgical-fires- in-the-uk-expert-working-group-recommendations- september-2020-r3572/


23 Vogel L. Surgical fires: nightmarish “never events” persist. CMAJ. 2018 Jan 29;190(4):E120. doi: 10.1503/cmaj.109-5548. PMID: 29378876; PMCID: PMC5790565.


24 Darouiche RO, Wall MJ Jr, Itani KM, Otterson MF, Webb AL, Carrick MM, Miller HJ, Awad SS, Crosby CT, Mosier MC, Alsharif A, Berger DH. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. N Engl J Med. 2010 Jan 7;362(1):18-26. doi: 10.1056/NEJMoa0810988. PMID: 20054046.


25 Day AT, Rivera E, Farlow JL, Gourin CG, Nussenbaum B 2018 Surgical Fires in Otolaryngology: A Systematic and Narrative Review Otolaryngology, Head and Neck Surgery, 158 (4) 598-616


26 Lampotang S, Gravenstein N, Paulus DA, Gravenstein D 2005 Reducing the incidence of surgical fires: supplying nasal cannulae with sub- 100% O2 gas mixtures from anesthesia machines, Anesthesia & Analgesia, 101 (5) 1407-1412


27 Kezze I, Zoremba N, Rossaint R, Rieg A, Coburn M, Schälte G 2018 Risks and prevention of surgical fires : A systematic review, Der Anaesthesist, 67 (6) 426-447


28 Bruley ME 2017 Challenges in Preventing Electrical, Thermal, and Radiation Injuries. In: Sanchez JA, Barach P, Johnson JK, Jacobs JP (ed) Surgical Patient Care: Improving Safety, Quality and Value Cham, Springer


29 Blazquez E, Thorn C 2010 Fires and explosions, Anaesthesia & Intensive Care Medicine, 11 (11) 455-457


30 Tola DH, Jillson IA, Graling P 2018 Surgical Fire Safety: An Ambulatory Surgical Center Quality Improvement Project, AORN Journal, 107 (3) 335- 344


31 Parremore R 2018 Introduction of the Surgical Site Fire Risk Assessment at The Lister Hospital, part of HCA Healthcare UK Journal of Perioperative Practice. https://doi. org/10.1177/1750458918813080


About the author


Mr Nigel D Roberts, MSc, BA (Hons) is a PhD student, head theatre practitioner, at Birmingham Children’s hospital, and a visiting lecturer at Birmingham City University. This paper is part of a literature review undertaken by the lead author towards the award of Doctor of Philosophy (PhD). It takes an exploratory approach to inform a more in-depth doctoral research study intended to improve patient safety in the operating theatre, inform policy making and quality improvement.


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