This newsletter is distributed to chief executive officers and survey coordinators at Joint Commission accredited organizations

A complimentary publication of The Joint Commission Issue 68, Oct. 18, 2023

Updated surgical fire prevention for the 21

century

An otherwise healthy patient is taken to the operating room for the removal of a

neck mole under monitored sedation. After the patient is given two liters of oxygen

through nasal cannula and administered intravenous sedation, an alcohol-based

skin preparation is applied to the surgical field.

As the surgeon uses electrocautery to coagulate bleeding, a flash occurs, and the

surgical drapes ignite. After extinguishing the fire by pouring water on the surgical

field, assessment of the patient reveals second-degree burns on the patient’s face.

Oxygen from the nasal canula had accelerated the fire and caused the nasal

cannula to melt and adhere to the patient’s face. The patient was transferred to the

burn unit for care, and ultimately required reconstructive plastic surgery.

This case illustrates one type of injury that can be sustained during a surgical fire.

Surgical fires continue to occur and represent a significant risk to patients and

healthcare professionals. This Sentinel Event Alert provides updated information

and replaces one on this topic that published in 2003. The Joint Commission issues

this alert to help healthcare organizations recommit to surgical fire prevention.

There is no national repository collecting data on surgical fires, therefore, reliable

data is difficult to obtain. ECRI, an independent, nonprofit organization dedicated to

improving the safety, quality and cost-effectiveness of care across all healthcare

settings worldwide, estimates that 90 to 100 surgical fires occur annually in the

United States.

Surgical fires may not be reported because of embarrassment,

potential adverse publicity, or the fear of investigation and possible litigation.

Internal, unpublished analyses of reports in the Joint Commission Sentinel Event

database have shown the leading factors contributing to surgical fires include

shortcomings in teamwork and communication, work design, workforce/staff, and

equipment. These factors include:

• A lack of a shared understanding and communication among surgical team

members before or during the procedure.

• Insufficient time-out to assess fire risk or to perform a workflow verification

step or safeguard.

• A lack of competency to understand or recognize risks.

• Overconfidence and risky behavior; distraction or loss of situational

awareness.

• Equipment malfunction or failure.

• A lack of training or orientation to the equipment in the operating room.

Minding the elements of the “fire triangle” can reduce occurrences of surgical fires

Surgical fires can be prevented by creating awareness of and carefully monitoring

elements of the “fire triangle:” 1) oxygen, 2) ignition sources and 3) fuel.

There are many potential contributing factors to surgical fires, including:

• Use of 100% alcohol for any preparation.

• Failure to allow alcohol-based field preparations to completely dry.

• Improper disposal of alcohol wipes or other prep material.

• Use of 100% oxygen.

• Poor training or failure to use proper precautions when employing

electrosurgical devices.

Published for Joint Commission

accredited organizations and

interested healthcare

professionals,

Sentinel Event

Alert

identifies specific types of

sentinel and adverse events and

high-risk conditions, describes

their common underlying causes,

and recommends steps to

reduce risk and prevent future

occurrences.

Accredited organizations should

consider information in a

Sentinel Event Alert

when

designing or redesigning

processes and consider

implementing relevant

suggestions contained in the

alert or reasonable alternatives.

Please route this issue to

appropriate staff within your

organization.

Sentinel Event Alert

may be reproduced if credited to

The Joint Commission. To receive

by email, or to view past issues,

visit www.jointcommission.org.

Sentinel Event Alert, Issue 67

Page 2

• Using electrosurgical devices in ENT

surgery with the patient under mask or

nasal cannula oxygen administration.

• Improperly handling and storing light cable

supply cords.

• Not placing an electrosurgical device back

in its holder when not in use.

Most surgical fires and burns are associated with

the use of an electrosurgical device while

performing head and neck surgery.

In the opening

case study, the ignition source is the electrosurgical

device, the fuel is undried, alcohol-based skin

preparation and surgical drapes, with oxygen

serving as the final element of the fire triangle.

Element 1 of the fire triangle: Elevated levels of

oxidizing agents increase the risk of fire

An elevated concentration of oxygen and other

oxidizing agents that together is greater than the

normal atmospheric oxygen level of 21% increases

the risk of fire by decreasing the temperature at

which fuels ignite.

Oxygen-enriched atmospheres

are reportedly involved in 75% of surgical fires.

The risk of fire is higher during head and neck, oral

pharyngeal and rectal procedures, particularly when

higher levels of oxygen or other oxidizers (e.g.,

nitrous oxide) may be present.

These highly

combustible gases, combined with flammable

substances in the airway and the energy of an

electrosurgical device/laser comprise the three

elements of the fire triangle that can result in an

airway fire. Examples of flammable substances that

may be present in airway fires include tracheal

tubes, catheters, and surgical sponges.

Bowel gas

ignitions are another source of surgical fires.

Element 2 of the fire triangle: Electrosurgical

devices – the most common ignition source

The use of electrosurgical devices cause about 70%

of the surgical fires occurring annually in the United

States.

One study found that surgical fires were

most common with monopolar “Bovie” instruments

(88% versus other instruments).

From Jan. 1, 2018

to March 29, 2023, 85 sentinel events related to

fires or burns during surgery or a procedure were

reported to The Joint Commission, with 58% of fires

or burns associated with electrosurgical devices,

and about 15% related to light sources for

electrosurgical devices.

Other potential ignition sources, especially within

oxygen-rich environments, are lasers and high-

speed drills producing incandescent sparks, as well

as coagulators, hot wire cautery and defibrillators.

Element 3 of the fire triangle: Alcohol-based skin

preparations among various fuel sources

Alcohol-based skin preparations, which are

recommended by the Centers for Disease Control

and Prevention for the preparations’ antiseptic

effectiveness,

are common fuel sources during

surgical fires

1,9

when not allowed to completely

evaporate. Other potential fuel sources include

surgical drapes, sponges, towels, gauze, methane in

bowel gas, and the patient’s body hair.

The Joint Commission requirements

Joint Commission Environment of Care (EC)

Standard EC.02.03.01 element of performance (EP)

11 requires accredited organizations – including

hospitals and office-based surgery centers – to:

• periodically evaluate potential fire hazards

that could be encountered during operative

or invasive procedures.

• establish written fire prevention and

response procedures, including safety

precautions related to the use of

flammable germicides or antiseptics.

In addition, the hospital or practice should:

• manage risks related to hazardous

materials and waste. (EC.02.02.01)

• mandate fire drills. (EC.02.03.03)

• collect information to monitor conditions in

the environment, and, at least annually,

review each environment of care

management plan’s objectives, scope,

performance, and effectiveness.

(EC.04.01.01)

Actions suggested by The Joint Commission

The Joint Commission suggests the following

actions to prevent surgical fires.

1. To satisfy the Joint Commission requirements

stipulated above, ensure that the time-out includes

a robust fire risk assessment (FRA) for each surgical

and endoscopic procedure. During a time-out before

each procedure, assess the risks associated with all

supplies and equipment to be used, including

inspecting them to assure they are in good working

order. Assess the location of the operation on the

patient and the presence of ignition sources, fuel

and oxygen in the environment. Have access to

saline within the operating room and fire

extinguishers in the procedural areas.

The FRA process from the AORN has been revised to

reflect risk identification and interventions to

Sentinel Event Alert, Issue 67

Page 3

address risks that are present. The recommended

questions include:

• Is an alcohol-based skin antiseptic or other

flammable solution being used

preoperatively? (Managing risks related to

hazardous materials and waste is one of

the Joint Commission requirements listed

above.)

• Is open oxygen or nitrous oxide being

administered and/or is the operative site

above the xiphoid process (e.g., head, neck,

chest) or in the oropharynx?

• Is an electrosurgical device, laser, or fiber-

optic light being used?

• Are any other ignition sources (e.g., battery-

powered cautery pens, defibrillators, drills,

saws, burrs) being used?

The FRA includes a scoring mechanism that

identifies the surgical fire risk as high, medium or

low. The score initiates a conversation among team

members to assure proper precautions.

addition, a key can be provided to further guide

steps to take in high-, medium-, or low-risk

situations.

2. Anesthesia should maintain the local oxygen

concentration at less than 30%, whenever

possible.

If the patient requires oxygen greater

than 30%, consider alternatives to using an open

oxygen delivery method, such as an endotracheal

tube (ETT) or laryngeal mask airway (LMA), if

clinically indicated.

Stop or reduce the delivery of supplemental oxygen

or nitrous oxide to the minimum required to avoid

hypoxia for at least one minute before the use of

electrosurgical devices; battery-powered, hand-held

cautery units; or lasers for head, neck, or upper

chest procedures.

The American Society of

Anesthesiologists (ASA) Task Force on Operating

Room Fires Practice Advisory

states that surgeons

should inform anesthesiologists before using a

potential ignition source, and anesthesiologists

should inform surgeons if there is a potential for an

ignition source to be exposed to an oxygen-enriched

environment.

3. Carefully manage electrosurgical devices, light

sources and cables, surgical draping, and other

risks during a procedure. These practices include

avoiding the use of electrosurgical devices in the

trachea or bowel;

9,13

using the lowest possible

power setting for the electrosurgical device and

keeping an active electrosurgical device or laser

away from gas sources and flammable materials;

and placing the electrosurgical device pencil/

handpiece or active electrode in a nonconductive

safety holster when not in use.

For light sources and cables, label illuminating light

sources warning of the burn risk when the cable is

not connected to the scope before activating the

light source.

Keep the light source at the lowest

brightness setting that allows for safe identification

and dissection during the case. Place the light

source in standby mode and disconnect the light

cord from the light source or place protective

covers/caps over the cord before use. Put the light

source into standby mode if the cable is

disconnected from the scope during surgery.

Keep

illuminated light cords away from drapes, patient’s

skin, personnel’s skin, and any flammable

material.

Even momentary proximity between an illuminated

laparoscopic or arthroscopic light lead and a

surgical drape can cause a skin burn. The risk of

injury rises with the brightness of the lamp used.

These types of burns often happen without the

knowledge of the surgical team because burns from

light sources associated with laparoscopic or

arthroscopic procedures typically do not produce

smoke or charring, even of surgical drapes.

Have the Safety Data Sheet (SDS) for alcohol-skin

preps and other potentially hazardous materials or

chemicals used during surgery accessible in the

surgical area, as well as in an area in the hospital

that is staffed 24/7. Use other cognitive aids, such

as one-page handouts or signs, to serve as safety

reminders prior to surgery or in case of emergency.

Assess hazards continuously during surgery. Each

surgical team member assesses hazards under

their own control, as well as observes the actions of

all other team members. When using an open

oxygen delivery device, configure surgical drapes

placed near the patient's head to allow oxygen to

flow freely and prevent accumulation under the

drapes.

Identify patients who have used mannitol-

based bowel preparations, who produce more gas

than those who used polyethylene glycol or sodium

sulfate preparations.

Use CO2 insufflation rather

than air insufflation during endoscopic procedures

to prevent bowel fires.

Encourage any member of the surgical team to

speak up immediately if any preventable risk or

evidence of a possible fire is observed.

4. Provide training to operating room staff on how to

avoid and manage fires and conduct fire drills, as

Sentinel Event Alert, Issue 67

Page 4

stipulated in the Joint Commission standards.

Define and review the roles and responsibilities of

each perioperative team member in the event of a

fire in the operating room, including turning off

ignition sources and managing fuel sources such as

alcohol-based preparations and drapes. For

example, the anesthesiologist bears primary

responsibility for halting an airway fire by stopping

the flow of oxygen to the patient.

Focus on the importance of communication and

situational awareness between team members

(including pre-op) during training. Surgical errors,

including fires, can result from faulty decision-

making, false assumptions, misperceptions,

distractions, and suboptimal decision-making

strategies.

Instruct surgical team members to

continually look for potential hazards within both

their and others’ areas of responsibility.

Practice responses to fires involving drapes, prep

solutions and equipment through simulation drills

and other training techniques.

This practice

includes instruction on how to turn off oxidizing

gases, use a fire extinguisher (whether water mist of

CO2), and activate the local fire alarm.

In addition, develop emergency evacuation

procedures and identify the responsibilities of each

team member. Identify evacuation sites as

comparable as possible to the operating room

environment. For example, if a patient requires

oxygen, suction or monitoring, they should be taken

to any patient care area where they can receive that

care.

Also practice moving/relocating the patient.

5. Report all surgical fires into your facility’s incident

reporting system, even if no injury to the patient

occurs. These reports provide opportunities to learn

and prevent future fires that could result in harm.

6. Encourage education of all operating room

personnel/team members about the risk of surgical

fires. The Society of American Gastrointestinal and

Endoscopic Surgeons (SAGES) offers the

complimentary

Fundamental Use of Surgical Energy

(FUSE) certification program for surgeons, as well as

providing hospital compliance modules for all

surgical team members. Encouraging this training is

particularly critical for organizations that conduct

endoscopic procedures.

In conclusion, surgical team members should be

aware of the elements of the fire triangle that create

“perfect storm” conditions in the surgical

environment that can result in a surgical fire. Each

member of the surgical team is responsible for

assessing all hazards that could contribute to a

surgical fire, as well as observing the action of all

other team members and speaking up immediately

if any preventive risk or evidence of a possible fire is

observed.

Resources

Fire prevention algorithms

These one-page handouts serve as useful

cognitive aids in the surgical environment.

American Society of Anesthesiologists

Anesthesia Patient Safety Foundation (APSF)

AORN Fire Prevention Assessment Protocol

(requires a subscription)

ECRI and APSF Surgical Fire Time-Out Poster

Other fire prevention resources

American Association of Nurse Anesthesiology

SAGES: Fire Prevention: Electrosurgical Safety in

Laparoscopy (video)

Fire Risk Score for Avoiding Fires in Operating

Room – An easy-to-use online tool for scoring fire

risk in the OR

References

1. Cowles Jr. CE and Culp Jr. WC. Prevention of and

response to surgical fires. BJA Education,

2017;19(8):261-266.

2. ECRI. Surgical Fire Prevention webpage.

Accessed September 9, 2023.

3. ECRI. Health Devices. 2009;38(10).

4. Akhtar N, et al.

Airway fires during surgery:

Management and prevention. Journal of

Anaesthesiology and Clinical Pharmacology,

2016 Jan- Mar;32(1):109-11.

5. Stormont G, et al. Surgical Fire Safety. (Updated

Jan. 29, 2023) In: StatPearls (Internet). Treasure

Island (FL): StatPearls Publishing; 2023.

6. Jones TS, et al. Operating room fires.

Anesthesiology, 2019;130:492-501.

7. The Joint Commission. Environment of Care (EC)

News. Making electrosurgery safer. May 2023,

26(5):13-16.

8. Overbey DM, et al. Surgical energy-based device

injuries and fatalities reported to the Food and

Drug Administration. Journal of the American

College of Surgeons. 2015;221:197-206.

9. Ehrenwerth J. Fire safety in the operating room

Up-To-Date, 2022.

10. Berríos-Torres SI, et al. Healthcare Infection

Control Practices Advisory Committee: Centers for

Sentinel Event Alert, Issue 67

Page 5

Disease Control and Prevention guideline for the

prevention of surgical site infection, 2017. JAMA

Surgery, 2017;152:784-91.

11. Osleger D. Preventing surgical fires with a surgical

or fire risk assessment. Jensen Hughes blog. Aug.

8, 2019.

12. Apfelbaum JL, et al. Practice advisory for the

prevention and management of operating room

fires. Anesthesiology 2013; 118: 271e90.

13. Association of periOperative Registered Nurses

(AORN). Fire Safety Tool Kit (requires a

subscription).

14. The Joint Commission. Quick Safety.

Preventing

light source-related burns from laparoscopy,

thoracoscopy and arthroscopy. Issue 69, April

2023.

15. Ball K. Lap Burn. Agency for Healthcare Research

and Quality, PS Net. Oct. 1, 2004.

16. Chitnavis J.

Silent burn: The hidden danger and

effects of bright light from fibre-optic cables in

arthroscopic knee surgery. Journal of Surgical

Case Reports, 2020 Apr 7;2020(4).

17. Graafland M, et al. Training situational awareness

to reduce surgical errors in the operating room.

British Journal of Surgery. 2015 Jan;102(1):16-

23.

18. Kezze I, et al. Risks and prevention of surgical

fires. Die Anaesthesiologie, 2018;67:426-447.

_____________________________________________

Patient Safety Advisory Group

The Patient Safety Advisory Group informs The Joint

Commission on patient safety issues and, with other

sources, advises on topics and content for Sentinel Event

Alert.