Preventing surgical fires

Fires rarely occur during an operation, but the estimated 650 surgical fires that do break out every year can inflict serious damage in a matter of seconds, according to the ECRI Institute, a not-for-profit scientific research firm, Plymouth Meeting, PA.* The most common surgical fire locations are the patient airway (34 percent), face or head (28 percent), and elsewhere inside or on the patient (38 percent). In addition to the human toll, surgical fires pose a hazard to the capabilities and long-term reputation of hospitals and ambulatory surgery centers (ASCs).

Surgical fires are among the ECRI’s top 10 technology hazards for 2013. In addition, surgical fire risks have been an issue frequently noted during Joint Commission accreditation surveys, prompting the commission to clarify standards expectations and offer strategies for this challenging compliance issue.

“Fire triangle”

Surgical fires occur when three primary elements—fire, heat, and an oxidizer—combine to create a fire triangle. Many flammable materials, or fuels, are present in the operating room (OR), including gowns, hoods, towels, blankets, masks, ointments, and dressings.

The most common heat sources in the OR are electrosurgical equipment, such as electrosurgical units (ESUs) or electrocautery units, fiber-optic light sources and cables, and lasers. Lasers, ESUs, and high-speed drills can create incandescent sparks that can jump off the tissue target and ignite specific fuels.

Oxygen, room air, and nitrous oxide are examples of oxidizers. Many surgical fires erupt in oxygen-enriched environments (OEEs), where the percentage of oxygen is higher than in typical room air. An example of an OEE would be environments in which patients are receiving supplemental oxygen, particularly via a mask or nasal cannula rather than a laryngeal mask. In an OEE, materials that may not otherwise combust in room air can ignite and burn. In 74 percent of all surgical fire cases, OEE was a contributing factor.

Preventing surgical fires

Fortunately, most surgical fires can be avoided when OR team members thoroughly understand the causes and dangers, follow Joint Commission standards and recommendations, and practice preventive measures. Several key Joint Commission Environment of Care (EC) standards and associated elements of performance (EPs) address fire safety. Hospitals and ASCs should review and follow these requirements to eliminate related hazards and minimize liabilities.

Among the accreditation standards are the following:

  • Standard EC.02.03.01 requires that organizations manage fire risks. EPs 9 and 10 of this standard are particularly valuable, requiring an organization to have a written fire response plan that describes the specific roles of staff and licensed independent practitioners at and away from a fire’s point of origin—including when and how to sound fire alarms, contain fire and smoke, use a fire extinguisher, and evacuate to safe areas.
  • Standard EC.02.03.03 mandates fire drills. EPs 1, 3, and 5 state that organizations should conduct these drills once per shift per quarter in each building defined by the Life Safety Code as a health care occupancy; each building defined by the Life Safety Code as an ambulatory health care occupancy should conduct these drills quarterly (with half of these quarterly drills classified as “unannounced”). A health care facility must critique its fire drills to assess and document fire safety equipment, building features, and staff response.
  • EPs 1, 2, 3 of EC.03.01.01 mandate staff and licensed independent practitioners to be familiar with their responsibilities and roles related to the EC. They should be able to demonstrate or describe methods for eradicating and reducing physical risks in the EC, actions to take in the event of an EC incident, and how to report EC risks. In addition, organizations should pay particular attention to EC.04.01.01, which stipulates that practitioners collect information to monitor conditions in the environment. EP 1 requires that a process or processes be established for sustained monitoring, internal reporting, and examination of several types of conditions, including injuries to facility occupants; property damage; fire safety management problems, failures, and deficiencies; and problems, failures, and user errors related to management of medical/laboratory equipment or utility systems.

Tips to prevent surgical fires

The Joint Commission recommends that hospitals and ASCs take the following actions to prevent surgical fires:

  • Inform staff members, such as surgeons and anesthesiologists, of the importance of controlling heat sources by adhering to laser and ESU safety practices, properly managing fuels by allowing adequate time for patient prep, and establishing guidelines for reducing oxygen concentration beneath drapes.
  • Develop, implement, and test procedures to ensure that all members of the OR teams are able to respond appropriately to OR fires. (This list includes full participation in the fire drills.)
  • Report to The Joint Commission, ECRI Institute, and the U.S. Food and Drug Administration any surgical fires in order to increase awareness and, most importantly, prevent fires.

For more information about preventing surgical fires, visit The Joint Commission to access Sentinel Event Alert Issue 29: Preventing surgical fires.


*ECRI Institute. Surgical fire protection. Available at: www.ecri.org/surgical_fires. Accessed June 25, 2013.
The Joint Commission. Sentinel Event Alert. Preventing surgical fires. 2003. Available at: www.jointcommission.org/assets/1/18/sea_29.pdf. Accessed June 25, 2013.
ECRI Institute. The top 10 health technology hazards for 2013. Available at: www.ecri.org/Documents/Secure/Health_Devices_Top_10_Hazards_2013.pdf. Accessed June 25, 2013.

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