$30 Million Dollars…that’s the amount awarded to a Washington State woman who has lost her ability to speak after a surgical fire during her February 2012 surgery. This 55 year-old woman was undergoing a laser-assisted polyp removal from her vocal cords and was on a breathing tube when fire broke out in her airway. Her injuries were serious, requiring multiple surgeries, and appear to be permanent.
While this incident and subsequent award has recently heightened our awareness, the severity of this issue has garnered attention and action throughout the past few years. With an estimated 550 to 650 surgical fires occurring in the US each year, in October 2010, the FDA introduced Preventing Surgical Fires, an initiative to address this concern. Providing resources, strategies and preventative guidelines to reduce the risk of surgical fires, this initiative is committed to three primary goals:
- increase awareness of factors that contribute to surgical fires
- disseminate surgical fire prevention tools
- promote the adoption of risk reduction practices throughout the healthcare community
Within this initiative, the FDA notes the three elements of a “fire triangle” that can lead to a surgical fire:
Ignition source (electrosurgical units (ESUs), lasers, fiber optic light sources)
Fuel source (surgical drapes, alcohol-based skin preparation agents, the patient)
Oxidizer (oxygen, nitrous oxide, room air)
Understanding these fire risks of each procedure and each team member’s role is key to reducing and preventing surgical fires. The surgeon, who is usually in control of the heat or ignition source, most commonly an electrosurgical unit, must use it safely and can remove it from the field if necessary. The anesthesia professional, usually in control of the supplemental oxygen source, can monitor and eliminate the oxidizer component of the fire triangle. The circulating nurse or scrub technician can help ensure meticulous application of alcohol-containing skin-prepping solutions and that they are dry before the application of surgical towels and drapes. They can also ensure occlusive draping when indicated and the availability of moist sponges, towels, and aqueous solutions, as well as keep exposed ends of fiber optic light cords off the surgical field.
Ultimately, a coordinated approach to surgical fire prevention and response by the surgical team is important to eliminate fire hazards and to minimize the time until the fire is extinguished.
Two years ago, I was appointed by the ASHRM Board of Directors to represent ASHRM on the FDA’s Preventing Surgical Fires initiative. It’s a privilege to work alongside of experts and professionals – from the medical, fire, equipment, insurance and patient care fields – dedicated to this important patient safety cause. The initiative’s website is the place to go to access resources and tools to implement at your facility. You don’t need to reinvent the wheel. These resources are free, accessible and easy to use. Every step should be taken to mitigate the risk and eliminate these fires.
Read more: Wenatchee World news article on $30 million award settlement in surgical fire case