What’s New in the Patient Safety World

January 2011

Surgical Fires Not Just in High-Risk Cases



While the risk of a surgical fire exists any time the elements of the “fire triangle” are present (fuel, heat source, and oxidizer), we generally think of those cases at high risk as being cases done on head and neck cases or procedures near the airway or involving the chest (see our Patient Safety Tips of the Week for December 4, 2007 “Surgical Fires” and April 29, 2008 “ASA Practice Advisory on Operating Room Fires” as well as all the excellent work done by ECRI on surgical fires and our November 2009 What’s New in the Patient Safety World column “ECRI: Update to Surgical Fire Prevention”). But fires can occur even in cases that might be considered low risk. One such case occurred in Israel during a C-section. The patient had been prepped prior to the planned surgery and allowed to dry off. However, in the OR the surgeon requested the field again be prepped with an alcohol-based prep. This was done and then he began an incision using a diathermy needle and a spark caused the resultant fire. The fire was extinguished and a healthy baby was delivered but the patient suffered severe burns and later required skin grafting to her buttocks and thighs. The Israeli health ministry noted the risk of fire is particularly dangerous in cases where the legs are elevated, promoting pooling of the alcohol-based prep under the buttocks (Even 2010). They also noted the sheets were flammable, which further complicated the case.


We have long advocated that the surgical fire risk be discussed as part of the pre-op huddle (or pre-op briefing) and, if the case is considered high-risk, respective roles of all OR participants are called out during the surgical timeout. As part of an effort to promote fire safety in the OR (Murphy 2010), the San Francisco VA has developed a checklist “The Surgical Fire Assessment Protocol”. This checklist/protocol is actually printed on the reverse side of their larger preoperative checklist. This is really a very good tool! The fire risk is assessed by a simple numerical scale. If the score is 3 (high risk) the rest of the form is filled out, which basically delineates the respective roles of all those participants. That’s a really good way to remind all about their responsibilities if a fire occurred.


But even that tool would probably not have flagged the above case as high-risk. It remains crucial that any time an alcohol-based skin prep is used, sufficient time be allowed for drying and a search for possible pooling be done. We know of some organizations that employ stop watches or timers in the OR to ensure adequate drying of alcohol-based preps.


Search for the ideal skin disinfectant that prevents surgical site infections but is not flammable is still ongoing. Several studies have now demonstrated that chlorhexadine/alcohol is a better disinfectant than providone-iodine. Unfortunately, the fire risk is much higher for the chlorhexadine/alcohol preparation. So careful attention to the drying time remains most important.






Woman Accidentally Set On Fire During C-Section

FoxNews.com  Published December 01, 2010




Even D. Operating theater accident sets pregnant woman alight. Hospital staff delivered a healthy baby, but the woman later needed plastic surgery for burns sustained in fire started by diathermic needle. Haaretz.com  December 1, 2010




Murphy J. A New Effort to Promote Fire Safety in the OR.

Topics In Patient Safety (TIPS) 2010; 10(6): 3




SF VAMC Surgical Fire Risk Assessment Protocol

















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