FDA Safety Communication – Reducing Surgical Fires

PUBLISHED: Jun 1, 2018
Relevant to: Ambulatory Care, Critical Access Hospitals, Hospitals

The US Food and Drug Administration (FDA) is reminding health care professionals and health care facility staff of factors that increase the risk of surgical fires on or near a patient. Although surgical fires are preventable, the FDA continues to receive reports about these events. Surgical fires can result in patient burns and other serious injuries, disfigurement, and death. Deaths are less common and are typically associated with fires occurring in a patient's airway.

Surgical fires can occur at any time when all three elements of the fire triangle are present:

  • Oxidizer (e.g., oxygen, nitrous oxide)
  • Ignition source (e.g., electrosurgical units (ESUs), electrocautery devices, lasers, and fiber-optic illumination systems)
  • Fuel source (e.g., surgical drapes, alcohol-based skin preparation agents, the patient’s tissue, hair, or skin)

Most surgical fires occur in oxygen-enriched environments, when the concentration of oxygen exceeds 30 percent. When supplemental oxygen is delivered to a patient in an operating room, an oxygen-enriched environment can be created. An open oxygen delivery system, such as nasal cannula or mask, presents a greater risk of fire than a closed delivery system, such as a laryngeal mask or endotracheal tube. In an oxygen-enriched environment, materials that may not normally burn in room air can ignite and burn.

Recommendations to Reduce Surgical Fires:

Health care professionals and staff who perform surgical procedures should be trained in practices to reduce surgical fires. Training should include factors that increase the risk of surgical fires, how to manage fires that do occur, periodic fire drills, how to use carbon dioxide (CO2) fire extinguishers near or on patients, and evacuation procedures. The FDA safety communication contains several recommendations to reduce surgical fires, including but not limited to:

  • Conduct a fire risk assessment at the beginning of each surgical procedure
  • Encourage communication among surgical team members.
  • Adopt safe use and administration of oxidizers
  • Adopt safe use of any devices that may serve as an ignition source
  • Adopt safe use of surgical suite items that may serve as a fuel source.
  • Plan and practice how to manage a surgical fire.

Included with today’s notice are example policies related to the prevention of surgical fires.

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