Monitoring OR fires to improve patient safety

When you see smoke in the operating room (OR), do you consider it a surgical fire? Under The Joint Commission’s updated definition, “fire, flame, or unanticipated smoke, heat, or flashes occurring during an episode of patient care” is considered a sentinel event, even if the source is extinguished and the patient is unharmed.*

The revised sentinel event definition became effective January 1 and was developed in an effort to encourage OR staff to investigate and take action whenever a fire occurs. Even though fires are not subject to mandatory reporting to The Joint Commission, under the sentinel event policy a comprehensive systematic analysis (such as a root-cause analysis) must be conducted in all instances of fire. The analysis is required to determine how an event happened and what can be done to prevent it from occurring again. The purpose of this activity is to establish a series of preventative steps that should be followed to avoid a recurrence. The process is meant to be non-punitive and is intended to help health care institutions improve patient safety.

Analysis of close calls or events where the patient is unharmed is important because the potential for patient injury exists every time there is a spark or smoke in the OR. An institution that is perpetually aware of opportunities for error and investigates these situations is exhibiting the characteristics of a high-reliability organization—one in which the goal is zero incidents of patient harm.

The Joint Commission and the American College of Surgeons both participate in the U.S. Food and Drug Administration’s (FDA) partnership, Preventing Surgical Fires. According to the FDA, an estimated 550 to 650 surgical fires occur in the U.S. annually, and despite the fact that the root causes of surgical fires are well understood, OR fires still occur.

The goals of the Preventing Surgical Fires initiative are to:

  • Increase awareness of factors that contribute to surgical fires
  • Disseminate surgical fire prevention tools
  • Promote adoption of risk-reduction practices

Health care professionals who are involved in a surgical fire are encouraged to report the event to The Joint Commission and to MedWatch, the FDA Safety Information and Adverse Event Reporting Program. Surgeons employed by institutions that are subject to the FDA’s user facility reporting requirements should follow the reporting procedures established by their facilities.

Reporting surgical fires

To help the FDA learn as much as possible about a surgical fire incident, the following information should be included in the reports:

  • Make and model of devices thought to be ignition sources (such as electrosurgical units, lasers, and fiberoptic cables)
  • Make and model of devices or drugs that were fuel sources (such as drapes or antiseptic skin preparation agents)
  • Whether supplemental oxygen was used and at what concentration
  • Delivery system used to supply supplemental oxygen (such as an endotracheal tube)
  • Any additional identifying information, including catalog and serial number
  • A complete description of the event, including patient outcome
  • The health care provider’s description of the event and thoughts on how the device contributed to the event
  • Device design or labeling that may have contributed to the event
  • Whether the device has been evaluated, including the evaluation results, if available

For more information, go to the FDA’s Preventing Surgical Fires.


*The Joint Commission. Sentinel Event Policy, January 2015. Available at: www.jointcommission.org/assets/1/6/CAMH_24_SE_all_CURRENT.pdf. Accessed March 25, 2015.

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