Surgical fires: decreasing incidence relies on continued prevention efforts
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Author(s):
- Burley, Mark E., author Arnold, Theresa V., author Finley, Edward, author Deutsch, Ellen S., author Treadwell, Jonathan R., author
- Contributor(s):
- Pennsylvania. Patient Safety Authority, issuing body.
- Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, June 2018
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Fires -- prevention & control Fires -- statistics & numerical data Medical Errors -- prevention & control Medical Errors -- statistics & numerical data Medical Errors -- trends Surgical Procedures, Operative Forecasting Patient Safety Risk Assessment Humans Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- Fires on the operating field, although preventable and declining in number, continue to be a hazard to patients and providers. The Pennsylvania Patient Safety Authority has updated its 2012 analysis of surgical fires reported through the Pennsylvania Patient Safety Reporting System. Using the same analytical criteria, analysts identified reports of fires submitted over the subsequent five years that occurred in the operating room (OR) on the sterile operating field and involved flaming combustion resulting from a combination of heat, oxygen, and fuel. Twenty-eight events that met the analysts' definition of fires on the operating field were reported from July 2011 through June 2016, equating to 5.6 fires per year in Pennsylvania. That incidence is down from the 10 fires per year found in the 2012 analysis and represents a 44.0% reduction since 2011. Since 2004, the rate of surgical fires varied from 0.83 per 100,000 OR procedures in the academic year 2005 (AY2005; July 2004 through June 2005) to 0.24 per 100,000 OR procedures in AY2016. This represents a statistically significant (p < 0.001) reduction in the patient risk of surgical fires of 71% since 2004. In this updated analysis, one-half of the reported events indicated some degree of harm to the patient. The operative sites of the head, neck, and upper chest constituted about two-thirds of the locations that were mentioned; oxygen-enriched atmospheres continue to be a major contributing factor to these incidents. Surgical fires with devastating consequences remain a significant risk. Facilities should consider using the Fire Risk Assessment Score and adhere to the recommendations of the American Society of Anesthesiologists Task Force on Operating Room Fires, the Anesthesia Patient Safety Foundation, and those of ECRI Institute.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
- Extent:
- 1 online resource (1 PDF file (12 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101735819 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101735819