What’s New in the Patient Safety World

November 2011

FDA Initiative on Preventing Surgical Fires



Another of our favorite topics: surgical fires (see list of our prior columns on this topic at the end of today’s column). The FDA has just launched an initiative aimed at preventing surgical fires. The resources contain a new video on surgical fires that nicely complements prior videos from ECRI and the Anesthesia Patient Safety Foundation. The video focuses on an approach taken by one healthcare organization after it experienced two surgical fires within an 8-month period. They incorporated a fire risk assessment into their Universal Protocol so that it gets done on virtually all surgical cases. The risk assessment is based on 3 simple questions about the fire triangle: (1) is there an open oxygen source? (2) is there a heat source present? and (3) how close are they to each other? (Note they assume that the “fuel” leg of the fire triangle is everpresent in the OR.) They then tie various protocols to the risk assessment score. The video describes the steps taken to mitigate the fire risk and also deals with improving communication among all members present in the OR and changing safety culture.


The October 13, 2011 FDA Safety Communication: Preventing Surgical Fires provides a concise summary of the scope of surgical fires and a list of good recommendations on how to prevent them. In addition, it has links to a variety of excellent resources on surgical fires and their prevention. The latter includes links to resources we’ve cited in our prior columns such as the ECRI and APSF resources, the Joint Commission Sentinel Event Alert on surgical fires, the AORN toolkit on surgical fire prevention, and a great reference we had not previously seen: a set of surgical fire safety documents from Christiana Care Health System.


Prevention of surgical fires requires an ever-present vigilance for risk factors, protocols to minimize those risks, and simulation training or drills so that all staff know what to do if a fire does occur.



Please also see our prior columns on surgical fires:


Patient Safety Tips of the Week:

·        December 4, 2007 “Surgical Fires

·        April 29, 2008 “ASA Practice Advisory on Operating Room Fires


What’s New in the Patient Safety World columns:

·        November 2009 “ECRI: Update to Surgical Fire Prevention”)

·        January 2011 “Surgical Fires Not Just in High-Risk Cases

·        March 2011 “APSF Fire Safety Video







FDA. Preventing Surgical Fires.




Silverstein KL, Joseph S. FDA on Medscape: Surgical Fires: How They Start and How to Prevent Them. October 12, 2011




FDA. FDA Safety Communication: Preventing Surgical Fires. October 13, 2011



Christiana Care Health System. Surgical Fire Risk Assessment.














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