Preventing Surgical Fires: Who Needs to be Educated?
Abstract:Background and Case Study: Surgical fires are rare but preventable. During facial surgery for a 68-year-old man, a fire broke out, resulting in first- and second-degree burns after a nasal cannula ignited in an oxygen-rich environment because of improper draping and tenting.
Discussion: Operating room (OR) fires can be prevented if any component of the "fire triangle"—fuels, ignition sources, and oxidizers—is reduced or eliminated. The use of supplemental oxygen in the OR via nasal cannulae, nebulizers, and oxygen cylinders must always considered a potential source of fire. Deficits in knowledge among the surgical team with respect to the prevention and management of surgical fires were apparent. A plan was put into place to improve fire safety education, entailing an educational program that is included in intern and resident orientation. Surgical fire safety training was also put into place for anesthesia and surgical faculty. The anesthesia preoperative evaluation was modified to include an assessment of the patients' ability to tolerate short periods without oxygen. Posters and signs are now displayed in each OR suite. A complete policy review and update ensures that at least two fire drills are performed annually.
Conclusion: Surgical fires can usually be prevented by educating staff about risk and prevention strategies. Such education should be part of all undergraduate medical, nursing, and other allied health profession education.
Document Type: Research Article
Publication date: September 1, 2005
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- Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.
David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.
Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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