Preventing surgical fires: who needs to be educated?

Document Type

Journal Article

Publication Date



Joint Commission journal on quality and patient safety / Joint Commission Resources








BACKGROUND AND CASE STUDY: Surgical fires are rare but preventable. During facial surgery for a 68-year-old man, a fire broke out, resulting in first- and second-degree burns after a nasal cannula ignited in an oxygen-rich environment because of improper draping and tenting. DISCUSSION: Operating room (OR) fires can be prevented if any component of the "fire triangle"-fuels, ignition sources, and oxidizers-is reduced or eliminated. The use of supplemental oxygen in the OR via nasal cannulae, nebulizers, and oxygen cylinders must always considered a potential source of fire. Deficits in knowledge among the surgical team with respect to the prevention and management of surgical fires were apparent. A plan was put into place to improve fire safety education, entailing an educational program that is included in intern and resident orientation. Surgical fire safety training was also put into place for anesthesia and surgical faculty. The anesthesia preoperative evaluation was modified to include an assessment of the patients' ability to tolerate short periods without oxygen. Posters and signs are now displayed in each OR suite. A complete policy review and update ensures that at least two fire drills are performed annually. CONCLUSION: Surgical fires can usually be prevented by educating staff about risk and prevention strategies. Such education should be part of all undergraduate medical, nursing, and other allied health profession education.