Connie Christian, MBA, CPHRM
Facility Risk Management and Patient Safety Advisor

Surgical fire prevention in facility surgical suites and office-based procedure rooms isn’t new. Unfortunately, lack of attention to this issue continues to cause patient harm and results in professional liability claims.

Surgical Fires in Facility Settings

The Joint Commission has issued updated guidance and requirements for their accredited facilities and practices in Sentinel Alert 68: Updated Surgical Fire Prevention for the 21^st Century. The Joint Commission guidance is practical and should be reviewed regardless of your accrediting body.

ECRI, an independent, nonprofit organization dedicated to improving the safety, quality, and cost-effectiveness of care across all health care settings worldwide, estimates that 90 to 100 surgical fires occur annually in the United States.[1]

Sentinel Alert 68 Findings

Internal, unpublished analyses of reports in the Joint Commission Sentinel Event database have shown the leading factors contributing to surgical fires include shortcomings in teamwork and communication, work design, workforce/staff, and equipment. These factors include:

• A lack of a shared understanding and communication among surgical team members before or during the procedure.
• Insufficient time-out to assess fire risk or to perform a workflow verification step or safeguard.
• A lack of competency to understand or recognize risks.
• Overconfidence and risky behavior; distraction or loss of situational awareness.
• Equipment malfunction or failure.
• A lack of training or orientation to the equipment in the operating room.

The Joint Commission Sentinel Event Alert 68 issued October 18, 2023.

Office-based Surgical Fires

Surgical fires are not just an issue for hospitals and ambulatory surgical centers. Office-based surgical procedures have also injured patients. A report by The Institute for Safe Medication Practices noted ETHYL CHLORIDE spray, which had been applied as a numbing agent to a patient’s big toe prior to a minor office surgical procedure. During the procedure, electrocautery was used, causing ignition of the ethyl chloride. The surgeon was able to smother the flame quickly; however, the patient suffered first-degree burns on his toe, which required wound care.

The front panel label on the ethyl chloride bottle includes a small icon of a flame, and–buried deep in the text–the side panel of the outer carton warns ethyl chloride should never be used in the presence of an open flame or electrical cautery equipment. However, the surgeon overlooked these inconspicuous warnings and was unaware of these risks.[2]

The Fire Triangle

The Joint Commission Sentinel Event Alert guidelines stress fire prevention can be achieved by awareness and monitoring of the Fire Triangle:

• Oxygen. Elevated levels of oxidizing agents increase the risk of fire.
• Ignition Sources. Electrosurgical devices are the most common ignition source.
• Fuel. Alcohol-based skin preparations are common fuel sources causing surgical fires.[3]

Loss Prevention Strategies:

• Ensure that the time-out includes a robust fire risk assessment (FRA) for each surgical and endoscopic procedure.

• Anesthesia should maintain the local oxygen concentration at less than 30% whenever possible.

• Carefully manage electrosurgical devices, light sources and cables, surgical draping, and other risks during a procedure.

• Train all staff involved in surgeries or procedures on how to avoid and manage fires and conduct fire drills.

• Report all fires involving patients into your facility’s or practice’s incident reporting system.

• Encourage educating all personnel and team members on the risk of surgical or procedure fires involving patients and your emergency plan for this occurrence.

KAMMCO encourages all members to review the Joint Commission Sentinel Alert 68 regardless of your affiliation. www.jointcommission.org/-/media/tjc/newsletters/sea-68-surgical-fire-prevention2-10-9-23-final.pdf

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[1] ECRI. Surgical Fire Prevention webpage. Accessed October 30, 2023.

[2] The Institute for Safe Medication Practices Surgical Fires Caused by Skin Preps and Ointments: Rare but Dangerous and Preventable March 8, 2018. www.ismp.org/resources/surgical-fires-caused-skin-preps-and-ointments-rare-dangerous-and-preventable Accessed October 30, 2023.

[3] The Joint Commission Sentinel Event Alert 68 issued October 18, 2023. Accessed October 30, 2023.