Medical Malpractice: Surgical Fire

Most Surgical Fires result from Medical Malpractice or negligence causing serious injury, disfigurement, and even death. They occur in, on or around a patient who is undergoing a surgical procedure. An estimated 550 to 650 surgical fires occur in the United States per year. Despite the fact that the root causes of surgical fires are well-understood, surgical fires still occur.

To promote actions to reduce the risk of risk of surgical fires.The Preventing Surgical Fires Initiative is celebrating its second anniversary during National Fire Prevention Week, October 6-12, 2013.

Fires happen during surgery because the 3 elements needed to start a fire (fire triangle) are present in an operating room:

1. the ignition source which could be a laser or an electrosurgical unit,
2. the fuel source, for example a surgical drape or or the skin of a patient that has been previously treated with alcohol 3. the oxidizer such as the supplemental oxygen or the nitrous oxide used for anesthesia
Most fires happen because of the high concentration of oxygen in the room.

To prevent these fires the FDA and partners including the ECRI Institue, the Anesthesia Patient Safety Foundation (APSF), the American Society of Anesthesiologists (ASA) and the Association of periOperative Registered Nurses have developed guideline to prevent operating rooms fire.

A fire risk assessment is now part of the the universal protocol, or the process by which a patient is confirmed to be the correct patient having the correct procedure at the correct time so the staff is also aware of the elements of the fire triangle in every single procedure.

Proper communications before and during the procedure between all members of the surgical team and specially between the anesthesia provider and the surgeon is also key in preventing these fires.

Below is a video from the FDA that explains how fire happen and what can be done to prevent them.