Despite attention in recent years, surgical fires continue to pose a serious threat to patients and staff, according to a recent Sentinel Event Alert from The Joint Commission (TJC). The alert updates one previously published in 2003. (The new Sentinel Event Alert is available online at: https://www.jointcommission.or....)
The new alert goes into more detail regarding the most common causes of surgical fires: airway surgeries using electrosurgical devices. It also focuses more on surgical teamwork.
Stronger Recommendations
In comparing the 2003 document to the recently released alert, it is apparent that TJC has strengthened its recommendations for fire safety in the operating room (OR), says Renae Wright, DNP, RN, CNOR, perioperative practice specialist with the Association of periOperative Registered Nurses (AORN) in Denver. Risk managers and OR managers should share this alert with their OR staff and use it to jumpstart a review of organizational policies and procedures related to fire safety in the OR.
“They should evaluate how well their current processes align with the new fire safety recommendations as well as observe staff in action to see if what is currently in place is being followed,” Wright says. “If practice doesn’t align with organizational policy and procedures or the new recommendations, it could be a good time to revise them and develop a comprehensive fire safety plan if one isn’t already in place.”
It is difficult to get an accurate picture of the current state of OR fire safety because there is no national repository that collects data on surgical fires, and reporting fire events to TJC is not mandatory, Wright notes. These events are underreported and will remain so unless something changes.
“As mentioned in The Joint Commission Alert, procedures involving the head and neck, including the oropharynx, are most often associated with reports of surgical fires,” Wright notes. “Precautions should address the risks that are present and include clear communication between the surgeon and anesthesia professional before an ignition source is used in the presence of an oxygen-enriched environment.”
Common Missteps
A common misstep is to rely on a fire risk score or category alone without taking action to address the risks that are present, Wright says. Unfortunately, a fire risk score or category on its own will not indicate which of the fire triangle components are present, nor will it provide a direct course of preventive action. The AORN Fire Risk Assessment and Prevention Algorithm directs users to intervene by asking four yes/no questions about the presence of fuels, ignition sources, and oxidizers, and then offers examples of interventions that can be applied to the identified risks.
(The AORN Fire Risk Assessment and Prevention Algorithm is available online at: https://www.aorn.org/article/3....)
“We know that OR fires are still happening, but unfortunately, without accurate reporting, we really don’t have a clear idea of the scope of the problem,” Wright says. “In lieu of hard data, what we can do is continue to push awareness of the issue, education on OR fire prevention, and team training that incorporates simulation to equip OR personnel to prevent surgical fires and know how to effectively manage them if they do occur.”
Risk managers can assist by ensuring these incidents are tracked and reported to their hospitals’ environment of care safety committee and governing bodies, says Herman McKenzie, director of engineering with the Standards Interpretation Group at TJC.
“This information should also be included as an agenda item for surgery and physician committee meetings. Once these incidents are tracked, healthcare organizations can do a deep dive to determine if there is a higher rate of these incidents occurring during specific procedures or with equipment and/or staff, including physicians,” McKenzie says. “Preventive measures should include periodic training and competency checks for staff working in the operating room.”
SOURCES
- Herman McKenzie, Director of Engineering, Standards Interpretation Group, The Joint Commission, Chicago. Phone: (630) 792-5800.
- Renae Wright, DNP, RN, CNOR, Perioperative Practice Specialist, Association of periOperative Registered Nurses, Denver. Phone: (800) 755-2676.
Despite attention in recent years, surgical fires continue to pose a serious threat to patients and staff, according to a recent Sentinel Event Alert from The Joint Commission.
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