When one reflects upon the dangers of surgery, fire is not usually at the top of the list. Operating room fires, though less common than other potential hazards such as wrong-site surgery, have seriously injured and even killed patients. And now data shows that they are more common than previously believed.
Pennsylvania, which collects some of the most comprehensive statistics, has had 28 operating room fires a year for the past three years – 1 in about every 87,000 surgeries. The state’s data, released in September, suggest that nationally there may be hundreds of such fires out of roughly 50 million inpatient and outpatient surgeries annually – not the 50 to 100 previously estimated by patient safety organizations. Massachusetts does not track operating room fires as closely as Pennsylvania, but health officials said hospitals in the Bay State have reported 18 fires or cases of smoke in operating rooms since 2005.
Several oversight groups, including the Department of Public Health and the Joint Commission, which inspects hospitals, have published warnings about surgical fires and recommended preventive measures since the early 2000s. For an overview of fires in surgical rooms see Preventing surgical fires.
In the past year, several professional organizations, including the American Academy of Otolaryngology – Head and Neck Surgery, the Association of periOperative Registered Nurses, and the American Society of Anesthesiologists, have also launched educational efforts.
Medical experts say such fires are a bizarre and persistent problem that often isn’t reported by hospitals and may be growing because of increasing use of new technologies. Since June 1, ECRI, an independent healthcare research organization, has counted six fires alone that caused serious harm. The fires appear to be rare–only about 100 are reported, with about 20 patients injured and two or three killed each year.
Fires in operating rooms have a long history in medicine. Traditionally, anesthesiologists used highly flammable gases such as ether to put patients to sleep, and doctors and nurses were vigilant about preventing fires. But as doctors began using less flammable anesthetics in the 1980s, prevention efforts started to wane. At the same time, other fire hazards grew, including the use of 100 percent oxygen, which can leak into the air, increasing the combustibility of gauze and hair; alcohol-based skin cleansers; and advanced surgical tools such as lasers and electrocautery devices.
According to hospital safety oversight group ECRI, 44 percent of operating room fires occur during head, face, neck, or chest surgery, when electrical surgical tools are closest to the oxygen the patient is breathing.
As with other types of surgical errors, such as wrong-site surgery, poor communication between surgeons, nurses, and anesthesiologists can be the root of the problem. Operating room safety specialists recommend that doctors use less than 100 percent oxygen during head and neck surgery, which surgeons store hot instruments off the operating table when they are not in use, and that doctors wait two or three minutes until alcohol-based products have evaporated from the skin before using cautery tools.
In one recent case, the surgeon told health investigators in 2003 that he applied an alcohol-based “skin prep” to the patient’s abdomen and chest before removing her gallbladder to help prevent postoperative infections. The substance is sticky, he said, so after he finished the operation, he applied an alcohol-based cleaner to remove it. He said he then remembered that he promised to remove a mole, so he grabbed the cautery device, and a flash fire occurred. A surgical scrub technician told health officials that he heard a sound similar to the lighting of a grill. The surgeon said the fire was extinguished in two to three seconds, but the patient had severe burns over her abdomen which took weeks to heal.