ReviewSurgical fires, a clear and present danger
Introduction
Of all the potential complications of surgery, a surgical fire is perhaps the most extraordinary. That patients who entrust themselves to medical care are actually set alight when at their most vulnerable seems almost unbelievable.1 Yet it happens, with alarming frequency and potentially devastating consequences.
Exact numbers are difficult to ascertain due to the absence of a standard reporting system and confidentiality clauses in many malpractice settlements2, but it does remain a relatively rare event.3 Estimates from the USA put the incidence at anything from 204, 5 to 6506, 7, 8 surgical fires each year. This makes the problem of a similar order of magnitude to wrong site surgery, a topic that has received far more attention in recent times.9 Three instances of surgical fires were reported to the National Reporting and Learning System in the UK between 2006 and 2009 (NPSA, personal communication). A US study found 17% of anaesthetic malpractice claims related to burns from surgical fires.10
Many will be minor fires causing no harm, but it is estimated that of the surgical fires that occur in the USA each year 20–30 are disabling or disfiguring and one or two are fatal.8 Airway injuries can necessitate prolonged intensive care with its accompanying morbidity.11
We present a review of the published literature on surgical fires and an examination of possible solutions to this problem.
Section snippets
Methods
The PubMed and Medline databases were searched using the subject headings “operating rooms”, “fire”, “safety” and “safety management”. “Surgical fire” was also searched as a keyword. The date range used was from 1948 onwards. Relevant references from articles were obtained. Relevant websites were identified using the Google internet search tool. Established patient safety organisations' websites were accessed for alerts and advisories relating to surgical fires.
Results
Over 400 relevant citations were identified. Many of these were case reports of specific fires. Some of these case reports also included a review of the literature as it was at the time. Other papers were non-clinical experiments exploring the conditions required for ignition, others still were intended to provide advice to clinicians in order to prevent further fires.
Conclusions
Surgical fire will always be a risk in the operating room. The danger is highest in head and neck surgery and where lasers are used. The risk can be mitigated by separating the elements of the fire triad from each other. This requires ongoing awareness of the threat and a concerted effort from all members of the operating theatre team.
Financial support
None.
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