Surgical fires occur 550 to 650 times per year and are comparable to the occurrence of other types of surgical mishaps. A fire that materializes on or in a surgical patient often has devastating consequences. Preventing these OR fires is crucial for any surgery center or hospital and there are several measures that should be in place, as the hospital in this case study learned.
During a patient safety initiative, a consultant interviewed the hospital risk manager and then proceeded to tour the facility. In this particular case, multiple departments were toured and all department managers were interviewed. In the perioperative department, the manager assisted with the walk-thru and discussion. As she described numerous processes the consultant asked her to explain: “fire safety in the OR”. She quickly outlined their bi-annual fire safety training, an exemplary part of any fire safety in the OR program. However, when asked about evaluating each patient’s individual risk of fire, she stated, “We have never done that”.
Implementing a process to reduce the risk of surgical fires to each patient undergoing a surgical procedure is a crucial step in improving overall safety in the OR suite. Suggestions included conducting a fire risk assessment prior to each procedure, incorporating the risk of fire into the “time-out” process and implementing a scoring system for each patient and procedure.
The Christiana Care Health System (CCHS) has demonstrated patient safety in action by developing a simple Fire Risk Assessment scoring tool. Implementing the CCHS tool would alert the surgical team to a high, moderate or low risk of surgical fire. The tool assesses three elements, and can easily be introduced into the “time-out” process.
After this, the perioperative department manager researched the CCHS Fire Risk Assessment tool and developed a plan to work with the staff on implementation.
Read our patient safety recommendations for surgical fires and find out more about prevention.
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