Patient Killed By Operating Room Fire

By ThinkReliability Staff

In a previous blog, we looked at possible causes of patient burns, including operating room fires.  Sadly, on September 8th, a patient passed away, six days after being burned during surgery.  (See the news article.)  Due to patient safety laws and ongoing investigations, there is no information suggesting what could have been the causes of the fire.  However, as with any fire, an operating room flash fire, like the one suspected in this case, requires 3 things:

1)  a heat source – typically in the operating room the heat source is provided by electrical surgical equipment.

2) oxygen – patients under anesthesia may be receiving 100% oxygen, providing an extremely oxygen-rich environment for fires.

3) fuel – the disposable synthetic fabrics primarily used now are more flammable than cloth drapes.

Since all three of these causes are required for a fire, removing any one of the causes will prevent a fire.  However, in an operating room environment it’s not practical to remove any one of these causes, so instead we can work on reducing the risk by mitigating the effect of each of these causes.  To reduce the risk from the heat source, surgeons are warned to leave electrical tools in standby mode, or turned off, whenever they are not in use.  To reduce the concentration of oxygen in the air, anesthetists may be asked to provide only as much oxygen as needed for the patient, and avoid creating places that oxygen may concentrate, such as under the drapes.  More flame-resistant material is being considered for use in some operating rooms.  Additionally, more and more operating room teams are providing training in preventing and extinguishing surgical fires, because although only an extremely small percentage of surgeries result in fire, the results can be catastrophic.