Tuesday, July 29, 2014


Earlier this month, Modern Healthcare published a story about the slow movement by hospitals to prevent operating room fires. An excerpt:

Despite a slew of news accounts about patients being set on fire in operating rooms across the country, adoption of precautionary measures has been slow, often implemented only after a hospital experiences an accident. Advocates say it's not clear how many hospitals have instituted the available protocols, and no national safety authority tracks the frequency of surgical fires, which are thought to injure patients in one of every three incidents. About 240 surgical fires occur every year, according to rough estimates by the ECRI Institute, a not-for-profit organization that conducts research on patient-safety issues. But fires may be underreported because of fear of litigation or bad publicity. 

“Virtually all surgical fires are preventable,” said Mark Bruley, vice president of accident and forensic investigation for ECRI, which has been tracking operating-room fires for 30 years. He blames the persistence of the problem on the slow migration of best practices across the hospital industry.  

Most surgical fires involve the ignition of concentrated oxygen by electrosurgical tools used in upper-body procedures, where patients receive the highly flammable gas through face masks and nasal devices. But a growing number are linked to the ignition of alcohol-based antiseptics.

Solid numbers on the incidence of operating-room fires do not exist. ECRI's latest estimate of 240 operating-room fires each year between 2004 to 2011 was revised down from earlier estimates of 650 fires a year between 2004 to 2007. 

While that suggests there has been improvement, studies of anesthesia malpractice claims suggest there's been a rise in incidents. “There is an inherent problem in preventing relatively rare events,” said Dr. John Clarke, clinical director of the Pennsylvania Patient Safety Authority. People think “it is not likely to happen to you in particular,” he said.

I was surprised and contacted a patient safety expert who replied, "No one believes it can happen to them, so they cut corners."

That seems to be the case in lots of places.  From the article:

Many of the best fire-safety practices developed in recent years stem from the work at Christiana Care Health System, Newark, Del., after two patients caught fire in operating rooms within eight months in 2003.

They pioneered their own process, which involves discussing the risk of fire during the scheduled time-out before surgery. The hospital hasn't burned a patient since.

Protocols like Christiana's have been widely disseminated. Yet, Christiana says it still get calls several times a month from hospitals that are just starting to implement a system. “It's a bit of an uphill slog,” said Dr. Kenneth Silverstein, chairman of Christiana's department of anesthesiology. “The bottom line is, in order to have a culture of safety in your institution, you have to get people behind it.” 

Sounds familiar.  We saw (and still see) hospitals go through the same slow process with central line infections, ventilator associated pneumonia, and other infection-related problems.  Maybe now it's time to yell, "Fire!"

2008 graphic from hpnonline.com


nonlocal MD said...

All the more reason to have a health care FAA and NTSB equivalent. Can you see airlines individually collecting and analyzing all that data on their own? (not to mention not sharing it, etc.) Why do we expect hospitals to do so?
Health care participants must be made to see that it is in their own best interests to support such a national effort before it is imposed upon them.

Paul Levy said...

Exactly right.

PJ Geraghty said...

"Most surgical fires involve the ignition of concentrated oxygen by electrosurgical tools used in upper-body procedures, where patients receive the highly flammable gas through face masks and nasal devices."

Except that oxygen itself is not flammable. It's an oxidixer, but fire requires fuel to burn (lots of fuel available in form of drapes, sponges, and alcohol-based antiseptic solutions soaking them) and energy to begin the reaction (electrocautery devices are a common source). Oxygen merely enhances the reactivity.

You can hold a lit match in front of an oxygen source and it will burn brighter and hotter, but the oxygen itself will never ignite the way (for example) propane does. (Usual "don't try this at home" disclaimer applies, of course.)