FDA continues to receive numerous reports of surgical fires from doctors and healthcare facilities across the U.S., the agency announced in a safety alert on Tuesday, despite the fact these are avoidable events. This is concerning to health authorities, as surgical fires can result in serious injury, permanent disfigurement, and even death.
There is a risk of surgical fires anytime 3 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)
FDA said that most surgical fires occur in oxygen-enriched environments, such as when supplemental oxygen is being delivered to a patient, when the concentration of oxygen is greater than 30%. In these situations, materials which are not typically flammable may ignite and burn, according to the safety communication.
All surgical staff should be familiar with best practices to avoid these events, FDA said.
“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.”
Additional recommendations to avoid surgical fires include:
- A fire risk assessment at the beginning of each surgical procedure
- Encourage communication among surgical team members
- Safe use of any devices that may serve as an ignition source
- Safe use of surgical suite items that may serve as a fuel source
- Plan and practice how to manage a surgical fire
FDA is working in conjunction with The Joint Commission (TJC) and other organizations to get the word out about the risks of fires in surgical settings, and in the process of reviewing product labeling for medical devices and other components that are part of the fire triangle to ensure their warnings are appropriate.