Surgical fires are fires that occur in, on or around a patient undergoing a medical or surgical procedure. Surgical fires are rare but serious events. The ECRI Institute estimates that approximately 550 to 600 surgical fires occur each year. The AANA is a collaborating partner of the FDA Preventing Surgical Fires Initiative. This initiative was launched to increase awareness of factors that contribute to surgical fires, disseminate surgical fire prevention tools, and promote the adoption of risk reduction practices throughout the healthcare community.
In most cases, surgical fires are preventable. As an integral part of the surgical team, it is important for CRNAs to be aware of potential hazards that may cause surgical fires, prevention techniques, and steps to extinguish a surgical fire. The AANA encourages all CRNAs to be knowledgeable about and take steps to mitigate the risk of surgical fires. It is important for anesthesia professionals to participate in a fire risk assessment, identifying the presence of the three elements of the fire triangle, at the beginning of each procedure. Continuous communication among the entire surgical team throughout the procedure is a vital component in the prevention of surgical fires.
Posters and Assessment Tools
Surgical Fires: How They Start and How to Prevent Them – Discussion between Stephanie Joseph from the FDA and Kenneth L. Silverstein, MD from Christiana Care Health System in Wilmington, Delaware.
Fires in the OR
This video from Dartmouth-Hitchcock Medical Center shows a modified time out procedure that includes a discussion of the steps each operating room team member would take to prevent a fire and the steps they would take if a fire occurred.
- Surgical Fire! 4 tips to keep patients safe, AORN, May 19, 2019
- FDA Safety Communication: Recommendations to reduce surgical fires and related patient injury
- APSF: Surgical fire issues continue to occur-prevention may require more cautious use of oxygen (includes fire prevention algorithm)
- APSF supplemental commentary and FAQs for anesthesia professionals related to the fire prevention video
- CSPS: Fire safety resources
- NFPA: Operation fire safety
- The Joint Commission: Sentinel Event Alert, Issue 29: Preventing surgical fires
- Roy S, Smith LP. Surgical fires in laser laryngeal surgery: are we safe enough? Otolaryngol Head Neck Surg. 2015;152(1):67-72.
- Apfelbaum JL, Caplan RA, Barker SJ, et al. Practice advisory for the prevention and management of operating room fires: an updated report by the American Society of Anesthesiologists Task Force on operating room fires. Anesthesiology. 2013;118(2):271-290.
- Mehta SP, Bhananker SM, Posner KL, Domino KB. Operating room fires: a closed claims analysis. Anesthesiology. 2013;118(5):1133-1139.
- Surgical Fires: Trends associated with prevention efforts. Pa Patient Saf Advis. Dec 2012;9(4):130-5
- Fairfax County jury awards $5.13 million in INOVA surgical fire case, Fairfax County Times, March 24, 2017
- Watch the News Report: patients who suffered severe burns from fires during surgery, March 4, 2016
- AANA contributes to article titled "Empowering providers to eliminate surgical fires", October 20, 2014
- Operating-Room Fire at Hospital Burns Patient, prompts changes, The Pilot, LLC, August 9, 2013
- Woman’s Face Set on Fire During Simple Surgery, FOX8 Cleveland, February 13, 2012
- Fires during surgeries a bigger risk than thought, www.boston.com, November 7, 2007
- Operating room fires: The CRNA and the deposition, AANA Journal, February 2007
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Surgical fires can occur any time all three of the following elements are present:
- Ignition source (e.g., electrosurgical units, lasers, and fiberoptic light sources)
- Fuel source (e.g., surgical drapes, alcohol-based skin preparation agents, the patient)
- Oxidizer (e.g., oxygen, nitrous oxide, room air)