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The JCAHO issues sentinel event alert on surgical fires

Hospital Safety Connection, June 26, 2003

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The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) on June 24 issued a Sentinel Event Alert on the dangers of surgical fires.

Of the more than 23 million inpatient surgeries and 27 million outpatient surgeries performed each year, there are an estimated 100 surgical fires that result in up to 20 serious injuries and one or two patient deaths annually, according to the JCAHO.

In nearly all cases studied by the Food and Drug Administration (FDA), the JCAHO, and research firm ECRI, the cause of a surgical fire can be traced to activities relating to one of the following elements: heat, fuel, or oxygen. The three elements make up the "fire triangle" and each must be present for a fire to start. The most common ignition sources are electrosurgical equipment (68%) and lasers (13%). The most common fire locations on are the patient's airway (34%), the patient's head or face (28%), and elsewhere on or inside the patient (38%), according to ECRI's analysis of case reports.

The JCAHO's recommendations for surgical fire prevention include the following:

* Inform staff members about the importance of controlling heat sources by following laser and electrosurgical safety practices; managing fuels by allowing sufficient time for patient prep; and establishing guidelines for minimizing oxygen concentration under the drapes

* Developing, implementing, and testing procedures to ensure appropriate response by all members of the surgical team to fires in the operating room

* Organizations should report any surgical fires to the JCAHO, ECRI, FDA, or state agencies

For more information on the alert, visit "www.jcaho.org"

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