At the end of 2011, two surgical fires occurred a week apart; one in Seattle in which a man was having a "procedure to remove a bump from his head" and one in Florida, when a 29-year-old mother had cysts removed from her head in an outpatient procedure.1 Both patients received burns to their heads and faces. The Seattle incident was believed to be caused by cautery, resulting in the patient's oxygen mask catching fire. The ambulatory surgery center in Florida released a statement that it's investigating the fire at its site; no initial cause was cited.1,2
These events reinforce what we know about surgical fires, which are more likely to occur on the face, head, neck, and chest, and often are ignited by cautery.3 An open oxygen delivery system poses more risk than a closed system such as a laryngeal mask.4 An estimated 550 to 650 surgical fires occur every year, some resulting in serious injury, disfigurement, and death. This number is comparable to the number of other surgical mishaps such as wrong-site surgery or retained instruments.3
The FDA, with the support of partners in the healthcare community, recently picked up the gauntlet in the prevention of surgical fires, which it identifies as preventable medical errors. To promote awareness and support safe practices, the FDA has launched the "Preventing Surgical Fires" initiative. The FDA regulates the drugs (for example, oxygen and skin preparation agents) and devices (for example, electrosurgical units and surgical drapes) that are components of the fire triangle, and reviews product labeling to ensure that they contain appropriate warnings about surgical fire risk.5
The FDA encourages patients to know about the risks of surgical fires, how they occur, and which surgical procedures pose higher risk for surgical fires. Patients should ask their healthcare providers if they're trained in preventing, recognizing, and putting out surgical fires and if water and carbon dioxide fire extinguishers are available.6 Healthcare organizations should provide annual fire prevention updates for their staff. The members of the surgical team should be prepared to answer these questions.
Surgical fires are always unexpected, so prevention is key, and centers on safe practices and communication. Each team member has control of an element of the fire triangle: surgeons control the ignition source, anesthesia providers manage the oxidizers, and nurses are in charge of fuel sources. Each discipline has a specific focus in controlling the components of the fire triangle, but all team members must encourage clear and effective communication, maintain situational awareness, and implement safe practices to prevent surgical fires. For more on the steps facilities can take to reduce the risk of these devastating fires, turn to the article by Evangeline (Vangie) Dennis, BSN, RN, CNOR, CMLSO, on page 37 of this issue. And visit our website to vote in the Quick Poll on surgical fire prevention.
Elizabeth M. Thompson, MSN, RN, CNOR
Editor-in-Chief Nursing Education Specialist Mayo Clinic, Rochester, Minn. [email protected]
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