How to prevent surgical fires, per Joint Commission

The Joint Commission recently updated its 20-year-old guidance on preventing surgical fires and burns, the organization said Oct. 18. 

There is no national reporting system that tracks the rate and risk of surgical fires, but the ECRI estimates that 90 to 100 surgical fires happen in the U.S. each year. 

Unpublished reports to The Joint Commission reveal that the causes of surgical fires include "shortcomings in teamwork and communication, work design, workforce/staff and equipment," according to the report. A few examples include "overconfidence and risk behavior," a lack of timeouts to assess a fire risk and equipment failures. 

This sentinel event alert, which replaces the guidance published in 2003, suggests hospitals focus on the "fire triangle," which refers to oxygen, ignition sources and fuel. 

For the first leg of the triangle, oxygen, the organization recommended hospitals be hypervigilant during operations that use high levels of oxidizers. This uptick in oxygen use is most often used in head and neck, oral pharyngeal and rectal procedures.

The Joint Commission similarly advocates for more attention to electrosurgical devices, the most common ignition source, and alcohol-based skin preparations, which is often fuel for a surgical fire. 

Here are six recommendations:

1. Ensure timeouts include a robust fire risk assessment for each surgical and endoscopic procedure.

2. Anesthesia should maintain the local oxygen concentration at less than 30% when possible. 

3. Carefully manage electrosurgical devices, light sources and cables, surgical draping and other risks during a procedure.

4. Provide training to operating room staff on how to avoid and manage fires and conduct fire drills. 

5. Report all surgical fires into your facility's incident reporting system, even if no injury to the patient occurs.

6. Encourage education of all operating room personnel/team members about the risk of surgical fires.

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