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Patient Safety Tip of the Week

May 7, 2019   Simulation Training for OR Fires



Some serious events are sufficiently rare that healthcare professionals may not be prepared to properly deal with them. Hence, hospitals and health systems need to include preparation for dealing with such occurrences. Surgical fires are one such example. In our many prior columns on surgical fires, we’ve stressed the importance of drills to prepare staff for the occurrence of a surgical fire. Simulation exercises are a good way to help staff prepare for emergencies.


Two excellent recent papers have focused on simulation exercises to prepare for surgical fires. Keane and Pawlowski (Keane 2019) describe the process at Boston’s Beth Israel Deaconess Hospital. They simulate a laparoscopic cholecystectomy and use a mannequin in their very realistic OR simulation center. They go through the usual prepping and draping and do a surgical timeout. A surgical fellow then prepares the laparoscope and sets it at his/her side while he/she and the surgeon begin to make incisions for port placement. A plume of smoke arises where the laparoscope has contacted drapes (see the full article for their unique mechanism for generating smoke and even projecting images of flames!). The participants respond by removing the drapes and any smoldering material that may harm the patient. The anesthesiologist assesses the patient’s airway and turns off all gases. The RN circulator provides normal saline to douse any flames or smoldering tissue on the patient. The RN circulator also activates a “code red” in the OR and brings the fire extinguisher into the room.


The team then debriefs and analyzes the various roles and responses that occurred during the simulation exercise. They also discuss things like availability of equipment and supplies. One person serves as the event manager. That person does not perform any specific task, but, rather, provides a global assessment and can assign new tasks as needed throughout the event.


It’s difficult to assess the impact of simulation when the real events are rare. The second paper, however, assessed both competency and confidence in handling fire-related safety after simulation. Kishiki and colleagues (Kishiki 2019) examined the effectiveness of OR fire simulation scenarios as a supplement to classroom-based training for managing OR fires. Groups were randomized. One group participated in one simulation after a classroom didactic session. The other group received two simulations, one before and one after the classroom didactic session. Competency scores were assessed for both groups. Those scores were higher for the group receiving 2 simulations and also improved after the second simulation. In addition, confidence scores were higher regarding fire safety-related tasks in the group undergoing 2 simulations.


Some of the elements you would assess during OR fire simulations are:

·       fire risk assessment

·       fire recognition (remember, it’s not always visual; in fact, it’s more often recognized by a “pop” or “swoosh”)

·       communication among team members

·       turning off oxygen

·       identifying and controlling the heat source

·       removing burning items from the patient

·       protecting the airway

·       extinguishing the fire

·       attending to patient burns or smoke-related injury


But keep in mind that these simulations only prepare staff to mitigate harm when a surgical fire occurs. In all likelihood, the patient will have already suffered some harm. The responses are primarily to limit the harm and begin to address harm that has already occurred to the patient.


These simulations should not distract from the primary goal: preventing surgical fires. Our previous columns have discussed in detail each of the elements of the “fire triad” (fuel, oxidizer, and heat source) and focused on key elements in prevention of surgical fires. These include assessing the risk of surgical fire, using tools such as the SF VAMC Surgical Fire Risk Assessment Protocol, developed at the San Francisco VA as part of an effort to promote fire safety in the OR (Murphy 2010), the Christiana Fire Risk Assessment Score or the AORN Fire Risk Assessment Tool.


Then, it is important to ensure that any alcohol-based skin preps have had adequate time to dry and have not pooled under drapes. And, probably most importantly, care needs to be taken to avoid free flow of supplemental oxygen. If oxygen is being used, there needs to be clear coordination between the surgeon and anesthesiologist to avoid the flow of oxygen while an electrocautery device, or other potential heat source, is being used.


We think you will find the AORN Fire Risk Assessment Tool Instructions to be an important resource since it spells out in detail all the steps that need to be taken when you have determined there is substantial risk for a surgical fire.


Another point we’d like to reiterate is that surgical fires are now most often occurring during what would be considered relatively “minor” procedures (eg. temporal artery biopsies, plastic procedures, or removal of skin lesions on the head/neck). We speculate there may be a couple reasons for that. One is that we probably “let our guard down” in dealing with such procedures, thinking they are simple procedures where little can go wrong. The other is that in such cases there may be no need for supplemental oxygen, yet supplemental oxygen is sometimes routinely provided. In others, use of supplemental oxygen is not anticipated but something occurs during the procedure that leads to its use.


We hope you’ll look at the many useful recommendations in our previous columns (listed below). And, of course, we again refer you to the valuable resources on surgical fires provided by ECRI Institute, AORN, the FDA, Christiana Care Health System and the APSF.



Our prior columns on surgical fires:







Keane J, Pawlowski J. Using Simulation for OR Team Training on Fire Safety. AORN Journal 2019; 109(3): 374-378 First Published:27 February 2019



Kishiki T, Su B, Johnson B, et al. Simulation training results in improvement of the management of operating room fires—A single-blinded randomized controlled trial. Am J Surg 2019; Published online: March 4, 2019



SF VAMC Surgical Fire Risk Assessment Protocol



Murphy J. A New Effort to Promote Fire Safety in the OR. Topics In Patient Safety (TIPS) 2010; 10(6): 3



Christiana Fire Risk Assessment Score



AORN Fire Prevention Assessment Tool



AORN Fire Prevention Assessment Protocol



AORN (Association of periOperative Registered Nurses). AORN Fire Safety Tool Kit.

Accessed September 3, 2018



ECRI Institute. Surgical Fire Prevention.



Christiana Fire Risk Assessment



FDA (US Food & Drug Administration). Recommendations to Reduce Surgical Fires and Related Patient Injury: FDA Safety Communication. FDA Safety Communication 2018; May 29, 2018



APSF (Anesthesia Patient Safety Foundation). Resources. Fire Safety Video. Prevention And Management Of Operating Room Fires.







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