Patient Safety Tip of the Week

January 29, 2008  Thoughts on the Recent Neonatal Nursery Fire



When we were putting together our December 7, 2007 Patient Safety Tip of the Week on Surgical Fires, we found the prospect of surgical fires to be, frankly, quite frightening! And one question we found ourselves asking was “Why aren’t there more fires in hospitals outside the OR?”. Given that there are so many areas in a hospital where oxygen is utilized, one would certainly expect to see some reports of accidental fires. There certainly have been episodic reports of fires due to patients or staff smoking near oxygen but few other reports of oxygen-related fires outside the OR.



This month there was a report from Mercy Hospital in Coon Rapids, Minnesota of an unfortunate incident in which a neonate suffered burns in a flash fire while in an open-topped bassinette under a warmer while using an oxygen hood. Though nurses promptly extinguished the flames, the infant suffered burns over about 18% of his head and body.



Allina Hospitals and Clinics, the parent organization of the hospital, has assembled a team to assist with the root cause analysis of the incident. Much to their credit, they have asked the ECRI Institute, which is the foremost authority on surgical fires, to participate in that RCA investigation. They are also coordinating the investigation with the Minnesota Department of Health, CMS, the Minnesota State Fire Marshall’s Office, and the local Police and Fire Departments. They expect the investigation to take 3-6 months. While some useful lessons learned may well emerge early in the RCA investigation, thoroughness and diligence in this case are critical. The circumstances in this unique case are likely to be replicated in multiple hospitals throughout the world every day. So it is extremely important that this investigation uncover key lessons to disseminate widely.



Fires have been reported in some oxygen-rich environments in hospitals. There have been over 50 deaths in a 20-year period of patients in hyperbaric oxygen chambers(1). Because of that known risk of fires, chamber operators typically perform a “safety check” to ensure a patient is not entering the chamber with any objects that might cause combustion or anything that might scratch the interior of the tank (2). Particularly with the recent proliferation of traditional and topical hyperbaric oxygen uses, whether evidence-based or otherwise, careful attention to the potential risk of fires is extremely important.



The Minnesota investigation undoubtedly will focus on some of the equipment typically used in the neonatal nursery, including the warming device, monitoring devices (including sensors), and any other electronic equipment in proximity to the oxygen. But keep in mind that in an oxygen-enriched environment any spark theoretically could lead to ignition. That could include a spark due to static electricity or a spark related to two pieces of metal coming in contact and undoubtedly many other commonplace occurrences. They will also undoubtedly take a close look at the configuration of the oxygen hood used to provide the therapeutic oxygen-enriched environment. They will also look for potential fire fuels (remember the fire triad: an oxidizer, a heat source, and a fuel). Combustible materials and substances are in common use in many areas of a hospital. Alcohol-based skin prep agents have been particularly hazardous in OR’s because they may saturate the covers/drapes and the vapors may become trapped(3). Of course, many hospitals now have made much more widespread use of alcohol-based disinfectants in their fight to avoid hospital-acquired infections. Conceivably, one of the unintended consequences of that battle might be an increase in the likelihood of inadvertently providing fuel for a rare fire. And there may be other lotions or creams being used therapeutically that are flammable.



Just as we need to ensure that everyone who enters an operating room has had appropriate training in surgical fire risk and procedures, we now need to consider similar training of everyone for any area in which oxygen is being used. This obviously would include not only staff, but everyone who might enter that area. That would include housestaff, agency personnel, and even parents and other visitors.



The patient safety community anxiously awaits the root cause analysis on the Minnesota case because its findings undoubtedly will impact on neonatal units everywhere



And, lastly, hospitals need to take a careful look to ensure that the clinical indications for use of concentrated oxygen are carefully adhered to. Just as in our discussions about the unnecessary use of urinary catheters, undoubtedly there are circumstances where neonates or other patients are “reflexly” begun on oxygen. Therefore, hospitals should have evidence-based criteria not only for starting oxygen therapy but also for its continuation and discontinuation.







Sheffield PJ, Desautels DA. Hyperbaric and hypobaric chamber fires: a 73 year analysis. Undersea Hyperb Med 1997; 24:153–64



Koetters K. Hyperbaric Oxygen Therapy. Journal of Emergency Nursing 2006; 32: 417-419



Recommended Practices for Electrosurgery. AORN Journal 2005; 81(3):616,618,621-624,626,629-632,635-636,638,641-642






Updates: See also our What’s New in the Patient Safety World columns for April 2008 “More Neonatal Incubator Fires” and March 2009 “Followup on the Minnesota Bassinet Fire”.








Patient Safety Tip of the Week Archive


What’s New in the Patient Safety World Archive