January 10, 2024
Any surgeon who has experienced a surgical fire knows how horrifying the event can be, and the results can be devastating for patients and their families.
Surgical fires continue to occur, causing significant harm not only to patients, but also to the surgical team and the operating room (OR) environment.
There isn’t a national repository that collects data on surgical fires; ECRI estimates that 90 to 100 surgical fires occur annually in the US.1
In order to help healthcare organizations and surgical teams recommit to surgical fire prevention, The Joint Commission issued a new Sentinel Event Alert, “Updated surgical fire prevention for the 21st century.”
The Alert stresses that each member of the surgical team is responsible for assessing all hazards that could contribute to a surgical fire, as well as observing the action of all other team members and speaking up immediately if any preventive risk or evidence of a possible fire is observed.
It is critically important that surgical teams become vigilant in preventing surgical fires in order to keep everyone safe. The operating theater has the perfect conditions for fire: ignition sources, oxygen, and fuel.
From January 1, 2018, to March 29, 2023, 85 sentinel events related to fires or burns during surgery or a procedure were reported to The Joint Commission. Of these fires or burns, 58% were associated with electrosurgical devices, and approximately 15% were related to light sources for electrosurgical devices.
The Joint Commission’s sentinel event database indicates that the leading factors contributing to surgical fires include shortcomings in teamwork and communication, work design, workforce/staff, and equipment. These include:
Healthcare organizations can significantly lower fire risk to patients, surgical teams, and the OR environment by developing processes and procedures that prevent dangerous interactions between oxygen, ignition sources, and fuel.
The Alert identifies the following evidence-backed actions to prevent fires:
The Alert details these safety steps and more.
The thoughts and opinions expressed in this column are solely those of Dr. Jacobs and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.
Dr. Lenworth Jacobs is a professor of surgery and professor of traumatology and emergency medicine at the University of Connecticut in Farmington and director of the Trauma Institute at Hartford Hospital, CT. He is Medical Director of the ACS STOP THE BLEED® program.