JCAHO Issues Alert on Surgical Fires

6/25/2003

From: Charlene D. Hill of the Joint Commission on Accreditation of Healthcare Organizations, 630-792-5175 E-mail: chill@jcaho.org

OAKBROOK TERRACE, Ill., June 25 -- The nation's leading advocate for health care quality and safety today called on hospitals and ambulatory surgery centers to reduce the risk of serious and deadly fires in operating rooms (see note a).

The bulletin issued by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) advises that such fires are significantly under-reported and are preventable. The Sentinel Event Alert urges greater reporting of surgical (see note a) fires as a means of raising awareness and ultimately preventing future fires. Reports can be made to organizations such as JCAHO, the Food and Drug Administration (FDA) and the independent health research agency, ECRI.

While considered rare occurrences, surgical fires are frightening and devastating experiences. Of the more than 23 million inpatient surgeries and 27 million outpatient surgeries performed each year, fires break out in surgical suites an estimated 100 times a year, resulting in up to 20 serious injuries and one or two patient deaths, based on data from the FDA and ECRI. Despite these figures, JCAHO's patient safety reporting database includes only two such cases since 1996.

Heat, fuel and oxygen, known as the "fire triangle," are in abundance in operating rooms across America. Flammable materials include alcohol prepping agents, surgical gowns, drapes, hoods and masks. Those materials can be ignited by heat from surgical lasers, electrosurgical equipment and high-intensity fiberoptic light sources. In addition, a high concentration of oxygen may be used during surgery to support the patient.

"The basic elements of a fire are always present during surgery and a misstep in procedure or a momentary lapse of caution can quickly result in a catastrophe," says Mark Bruley, vice president, Accident and Forensic Investigation, ECRI.

These dangers mean that each member of the surgical team - the surgeon, the anesthesiologist and the nurses - must work to manage their specific side of the fire triangle to avoid danger. JCAHO's Alert recommends that health care organizations help prevent surgical fires by educating staff members about the importance of controlling heat sources by following laser and electrosurgical unit safety practices. JCAHO also suggests managing potential fire fuels by allowing sufficient time for patient prep and establishing guidelines for minimizing oxygen concentration under the drapes.

The warning about surgical fires is the latest in a series of patient safety alerts issued by JCAHO. Previous alerts have focused on hospital-acquired infections, wrong-site surgery, deadly medication mix-ups, patient suicides, infant abductions and fatal falls among the elderly.

Making patient safety its top priority, JCAHO has established one of the nation's most comprehensive voluntary reporting systems for health care errors. The resulting database includes detailed information about the causes of the errors, and has enabled JCAHO to both warn health care facilities about dangers and share solutions to prevent these tragedies. The complete list and text of past issues of Sentinel Event Alert can be found on JCAHO's Web site at http://www.jcaho.org.

NOTE (a): The terms surgical and operating room include all invasive procedures and the locations where they are done.

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Founded in 1951, the Joint Commission on Accreditation of Healthcare Organizations seeks to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. The Joint Commission evaluates and accredits nearly 17,000 health care organizations and programs in the United States, including approximately 9,000 hospitals and home care organizations, and 8,000 other health care organizations that provide long term care, assisted living, behavioral health care, laboratory and ambulatory care services. The Joint Commission also accredits health plans, integrated delivery networks, and other managed care entities. An independent, not-for-profit organization, the Joint Commission is the nation's oldest and largest standards-setting and accrediting body in health care.