Fowler Associates Labs

Danger: Operating room flash fires

Paraphrased by:
Steve Waldrop
December 19, 2003

Imagine going into a hospital for routine surgery and waking up so severely burned that you are unrecognizable. It may sound hard to believe, but it's happening often enough that a national health care commission recently took the unusual step of issuing an alert to hospitals.

The Joint Commission on Accreditation of Healthcare Organizations, which accredits 17,000 hospitals nationwide, estimates that between 100 and 200 operating room fires break out each year.

Hospital systems across the country are putting into place an aggressive training program for their operating staff. Operating room workers get classroom and hands-on training. The program warns of a fire triangle: oxygen, available fuel and an ignition source. Each element must be present for a fire to start, and many times all three elements come together in a hospital's surgical unit.

It's difficult to tell how many operating room fires break out because hospitals are not required to report them to any federal agency. But some sources estimate that there are close to 100 surgical fires each year which could possibly result in serious injuries to patients and in some cases even death.

Many flammable materials are found in the surgical suite, from the wide range of alcohol-based prepping agents and linens such as drapes, towels, gowns, hoods and masks; to the multiple types of dressings, ointments and equipment and supplies used during surgery. Common ignition sources found in the operating room are electrosurgical or electrocautery units fiberoptic light sources and cables; and lasers. In addition, lasers and high-speed drills can produce incandescent sparks that can fly off the target tissue and ignite some fuels, especially in oxygen-enriched atmospheres.

"The basic elements of a fire are always present during surgery and a misstep in procedure or a momentary lapse of caution can quickly result in a catastrophe," says Mark Bruley, vice president, Accident and Forensic Investigation, ECRI (Emergency Care Research Institute). "Slow reaction or the use of improper fire-fighting techniques and tools can lead to damage, destruction or death." Bruley also notes that virtually all surgical fires are preventable and that their impact can be lessened through an understanding of fire and how to fight it. "Each member of the surgical team—the surgeon, the anesthesiologist, and the nurses—controls a specific side of the triangle and by properly managing their technique and part of the equation, surgical fires can be avoided," says Bruley.

Patients should always ask about safeguards the hospital has in place to prevent fires.
Remember, ask questions, It's your life!