Surgical Fires
Surgical Fires Overview
Surgical fires are fires that occur in, on, or around a patient undergoing a medical or surgical procedure. Surgical fires are rare but serious events. The ECRI Institute estimates that approximately 550 to 650 surgical fires occur each year.
In most cases, surgical fires are preventable. As an integral part of the surgical team, it is important for CRNAs/nurse anesthesiologists to be aware of potential hazards that may cause surgical fires, prevention techniques, and steps to extinguish a surgical fire.
The AANA encourages all CRNAs/nurse anesthesiologists to be knowledgeable about and take steps to mitigate the risk of surgical fires. It is important for anesthesia professionals to participate in a fire risk assessment, identifying the presence of the three elements of the fire triangle, at the beginning of each procedure. Continuous communication among the entire surgical team throughout the procedure is a vital component in the prevention of surgical fires.
Surgical fires can occur any time all three of the following elements are present:
- Ignition source (e.g., electrosurgical units, lasers, and fiberoptic light sources)
- Fuel source (e.g., surgical drapes, alcohol-based skin preparation agents, the patient)
- Oxidizer (e.g., oxygen, nitrous oxide, room air)
Surgical Fires Resources
Assessment Tools and Videos
Assessment Tools and Videos
- Christiana Care Health System: Surgical Fire Risk Assessment
- APSF: Prevention and Management of Operating Room Fires
- Surgical Fires: How They Start and How to Prevent Them – Discussion between Stephanie Joseph from the FDA and Kenneth L. Silverstein, MD from Christiana Care Health System in Wilmington, Delaware.
- AORN Periop Today: 3 Risks for Fire in the OR & the Interventions You Need to Protect Patients
News Reports
News Reports
- Fairfax County jury awards $5.13 million in INOVA surgical fire case, Fairfax County Times, March 24, 2017
- AANA contributes to article titled “Empowering providers to eliminate surgical fires“, AORN Journal, October 20, 2014
- Operating-Room Fire at Hospital Burns Patient, prompts changes, The Pilot, LLC, August 4, 2015
- Woman’s Face Set on Fire During Simple Surgery, FOX8 Cleveland, February 13, 2012
Prevention
Prevention
- APSF supplemental commentary and FAQs for anesthesia professionals related to the fire prevention video
- CSPS: Fire safety resources
- The Joint Commission: Sentinel Event Alert 68: Updating Surgical Fire Prevention for the 21st Century
- Roy S, Smith LP. Surgical fires in laser laryngeal surgery: are we safe enough? Otolaryngol Head Neck Surg. 2015;152(1):67-72.
- Apfelbaum JL, Caplan RA, Barker SJ, et al. Practice advisory for the prevention and management of operating room fires: an updated report by the American Society of Anesthesiologists Task Force on operating room fires. Anesthesiology. 2013;118(2):271-290.
- Mehta SP, Bhananker SM, Posner KL, Domino KB. Operating room fires: a closed claims analysis. Anesthesiology. 2013;118(5):1133-1139.
- Surgical Fires: Trends associated with prevention efforts. Pa Patient Saf Advis. Dec 2012;9(4):130-5
Disclaimer
The resources on this page may incorporate or summarize views, guidelines, or recommendations of third parties. Such material is assembled and presented in good faith, but does not necessarily reflect the views of the AANA. Links to third-party websites are inserted for informational purposes and do not constitute endorsement of the material on those sites, or of any associated organization.