Preventing Surgical Fires

Surgical Fires:
Prevention is the Ultimate Goal

According to the Council of Surgical Perioperative Safety (CSPS), an estimated 550 to 650 surgical fires occur in the United States per year, some causing serious injury, disfigurement, and even death. Despite the fact that the root causes of surgical fires are well-understood, surgical fires still occur.

My own observations through consulting have corroborated the statistics. I have witnessed too many ignition devices in the outpatient or procedural areas (including physician offices) where the staff were not familiar with fire risk assessments. Combine that with the vast use of alcohol skin preps and the oxygen/nitrous oxide used in these areas, and conditions are primed for increased risk of fire and patient harm.

The number of procedures taking place outside of the operating room has rapidly increased, and with use of electrosurgical equipment (ESU) more events are being reported. Surgical fires can occur any time all three elements of the “fire triangle” (ignition source, fuel source, and oxygen) are present.

Each member of the surgical or procedural team plays an important role in patient safety. When teams are educated and made aware of how to properly manage all three components (ignition source, fuel source, and oxygen), surgical fires can be prevented easily.

The fire risk triangle

How Do Surgical Fires Happen?

Emergency Care Research Institute’s recent analysis of case reports showed that the most common ignition sources are electrosurgical equipment (68%) and lasers (13%). Most surgical fires occur in an oxygen enriched environment, when the concentration of oxygen exceeds 30%. When supplemental oxygen is delivered to a patient an oxygen rich environment can be created. In an oxygen rich environment, even materials that may not normally burn can ignite.

Each member of a surgical/procedural team controls a certain aspect of this triangle:

  • Surgeons/proceduralists control the heat/ignition source (ESU, fiberoptic light source, lasers).
  • Nurses control the fuel source (alcohol-based skin prep, surgical drapes, patient).
  • Anesthesiologists control the oxidizer (oxygen, nitrous oxide, room air).

The American College of Surgeons, the American Society of Anesthesiologists (ASA), and the Association of Perioperative Registered Nurses (AORN) have all developed training manuals and recommendations aimed at reducing the risk of fires through education. Prevention is the ultimate goal for fire safety.

Recommendations by the FDA to Mitigate the Risk of a Fire in the Surgical or Procedural Area

The FDA recommends that a fire risk assessment is completed at the beginning of each procedure involving an ignition source, fuel source, and oxidizer. When flammable germicides or antiseptics are used during surgeries utilizing electrosurgery, cautery, or lasers, Joint Commission EC.02.03.01 EP12 indicates that nonflammable packaging, unit dose applicators, and a preoperative “time-out” are required. The preoperative “time-out” should be conducted prior to the initiation of any surgical procedures, and should verify the following:

  • Application site is dry prior to draping and use of surgical equipment
  • Pooling of solution has not occurred or has been corrected
  • Solution-soaked materials have been removed from the operating room prior to draping and use of surgical devices (refer to NFPA 99-2012:15.13)

Ensuring open communication among the healthcare team is another way to mitigate risk. Is every team member vigilant about speaking up when they see a fire risk, such as in improperly holstered electrocautery pencil or a hurried team overlooking alcohol prepping solution dry time?

Evaluate if supplemental oxygen is needed. If so, can a closed system be used or titrate the minimum concentration of oxygen needed to maintain adequate oxygen saturation for the patient. Safe use and administration of oxidizers plays a critical role in fire safety, as well as the safe use of any devices that may serve as an ignition source by following the manufacturer’s instruction for use.

  • If high concentrations of supplemental oxygen are being delivered, consider alternatives to using an ignition source for surgery of the head, neck, and upper chest.
  • Inspect all instruments for evidence of insulation failure prior to use.
  • Cautery tips must be kept clean and free of char and tissue.
  • Ensure all electrocautery devices, fiberoptic light sources, and lasers are in a designated area away from the patient and not directly on the patient or surgical drapes.

Following the manufacturer’s instructions for use will also ensure safe use of surgical items that may serve as a fuel source. This includes:

  • Allowing adequate dry time and preventing alcohol-based antiseptics from pooling during skin preparation
  • Using the appropriate size applicator for the surgical site
  • Awareness of products that may trap oxygen, such as surgical drapes, towels, sponges and gauze (even those that claim to be fire resistant)
  • Products made of plastics including endotracheal tubes, laryngeal masks, and suction catheters
  • Patient related sources such as hair and gastrointestinal gases

Finally, it’s important to have a plan and practice how to manage a surgical fire.

  • Stop the main source of ignition. Turn off the flow of flammable gas and unplug electrical devices that may be involved.
  • Extinguish the fire. Use a safe method to smother the fire (such as water or saline), and a CO2 (or other) extinguisher if the fire persists.
  • Remove all drapes and burning materials and assess for evidence of smoldering materials.
  • For airway fires, disconnect the patient from the breathing circuit and remove the tracheal tube.
  • Move the patient to a safe environment. Reestablish the airway to resume respiratory care.
  • Review the fire scene and remove all possible sources of flammable materials.

Performing a Fire Risk Assessment

  1. Perform before the start of the procedure.
  2. All members of the team participate.
  3. Communicate this assessment during the “time out.”
  4. Document the assessment in the patient’s record.
  5. Note ignition sources that are present.
  6. Note fuels that are present.
  7. Assess the potential for the presence of an oxygen-enriched environment.

Fire Risk Assessment Tool

The AORN recommends using the following questions in a fire risk assessment:

  1. Is an alcohol-based skin antiseptic or other flammable solution being used preoperatively?
  2. Is the operative or other invasive procedure being performed above the xiphoid process or in the oropharynx?
  3. Is open oxygen or nitrous oxide being administered?
  4. Is an electrosurgical unit, laser, or fiber-optic light being used?
  5. Are there other possible contributors, such as defibrillators, drills, saws, or burrs?

Regulatory Survey Tips

During a regulatory survey the procedural team may be asked what your facility is doing to reduce the risk of fires related to alcohol-based skin preps. Your team will be wise to know your skin prep products and their manufacturer’s instructions for use related to dry time. Make sure your team knows the steps for surgical fire prevention, including the components, ignition sources, oxidizers and fuels.

Be sure to communicate with your team about the fire risk assessment. Each member of the surgical or procedural team plays an important role in patient safety. With more procedures taking place outside of the operating room it is critical that we identify those areas using the three components of the fire triangle (ignition source, fuel source, and oxygen) to keep our patients and staff safe and free of any risk of fire. The procedural/surgical team must take a collaborative and systematic role following these guidelines to master fire prevention. Early detection and preventative efforts will support a safe patient care environment and workplace.

TiER1 Healthcare Can Help.

TiER1 Healthcare can help your team form a complete approach to providing a safe and effective care environment. Contact us at (800) 241-0142 or for a consultation.


NFPA 101: Life Safety Code. Quincy, MA: National Fire Protection Association

FDA: Preventing Surgical Fires

Association of Perioperative Registered Nurses (AORN): Fire Safety Tool Kit

Council on Surgical & Perioperative Safety (CSPS): Safe Surgery Resources

Anesthesia Patient Safety Foundation (APSF): Fire Safety Video

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