Advertisement

Fire in the Operating Room: Surgical Case Report From a Forced-Air Warming Device Equipment Fire

      ABSTRACT

      Surgical fires are critical life-threatening events that can result in patient morbidity and mortality. This case report describes an equipment fire originating from a forced-air warming device occurring during a shoulder arthroscopy operation and discusses how the surgical team responded to mitigate risks to the patient and staff. Rapid response by the anesthesia professional and the surgical team helped prevent the fire from negatively impacting patient and staff safety. The patient was discharged from the hospital without any complications. We recommend that surgical teams engage in a coordinated and continual cycle of fire prevention, including enhanced education and interprofessional team training.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of PeriAnesthesia Nursing
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. The Joint Commission. Sentinel Event Alert 29: Preventing surgical fires. The Joint Commission. Available at: https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-issue-29-preventing-surgical-fires/. Accessed December 5, 2021.

      2. AORN. AORN Fire Safety Tool Kit. Association of periOperative Registered Nurses; 2021. Available at: https://test.aorn.org/guidelines/clinical-resources/tool-kits/fire-safety-tool-kit. Accessed December 5, 2021.

        • Bruley M
        • Arnold T
        • Finley E
        • Deutsch E
        • Treadwell J.
        Surgical fires: Decreasing incidence relies on continued prevention efforts.
        Pa Patient Saf Advis. 2018; (06/01)
      3. Institute for Safe Medication Practices. Surgical fires caused by skin preps and ointments: Rare but dangerous and preventable. Available at: https://www.ismp.org/resources/surgical-fires-caused-skin-preps-and-ointments-rare-dangerous-and-preventable. Accessed January 30, 2022.

        • Choudhry AJ
        • Haddad NN
        • Khasawneh MA
        • Cullinane DC
        • Zielinski MD.
        Surgical fires and operative burns: Lessons learned from a 33-year review of medical litigation.
        Am J Surg. 2017; 213: 558-564https://doi.org/10.1016/j.amjsurg.2016.12.006
        • Jardaly A
        • Arguello A
        • Ponce BA
        • et al.
        Catching fire: Are operating room fires a concern in orthopedics?.
        J Patient Saf. 2021; https://doi.org/10.1097/PTS.0000000000000896
      4. AHRQ. Patient Safety Network. Agency for Healthcare Research and Quality. Available at: https://psnet.ahrq.gov/primer/never-events. Accessed December 5, 2021.

        • Jones TS
        • Black IH
        • Robinson TN
        • Jones EL.
        Operating room fires.
        Anesthesiology. 2019; 130: 492-501https://doi.org/10.1097/ALN.0000000000002598
        • Kezze I
        • Zoremba N
        • Rossaint R
        • Rieg A
        • Coburn M
        • Schalte G.
        Risks and prevention of surgical fires: A systematic review.
        Anaesthesist. 2018; 67 (Risiken und Pravention chirurgisch induzierter Feuer: Eine systematische Ubersicht): 426-447https://doi.org/10.1007/s00101-018-0445-2
        • Mehta SP.
        Burn injuries from warming devices in the operating room.
        ASA Newsl. 2013; 77: 16-17
        • Lalla RK
        • Koteswara CM.
        Fire in the operating room due to equipment failure.
        J Anaesthesiol Clin Pharmacol. 2013; 29: 141https://doi.org/10.4103/0970-9185.105836
      5. Agency for Healthcare Research and Quality (AHRQ). TeamSTEPPS: Strategies and tools to enhance performance and patient safety. Available at: https://www.ahrq.gov/teamstepps/instructor/index.html. Accessed December 01, 2021.

      6. ERCI. Surgical Fire Prevention. Emergency Care Research Institute Available at: https://www.ecri.org/solutions/accident-investigation-services/surgical-fire-prevention. Accessed December 5, 2021.

        • Apfelbaum JL
        • Caplan RA
        • Barker SJ
        • et al.
        Practice advisory for the prevention and management of operating room fires: An updated report by the American Society of Anesthesiologists Task Force on operating room fires.
        Anesthesiology. 2013; 118: 271-290https://doi.org/10.1097/ALN.0b013e31827773d2
      7. The Anesthesia Patient Safety Foundation. Prevention and management of operating room fires video. Available at: https://www.apsf.org/videos/or-fire-safety-video/. Accessed January 30, 2022.

        • Truong H
        • Qi D
        • Ryason A
        • et al.
        Does your team know how to respond safely to an operating room fire? Outcomes of a virtual reality, AI-enhanced simulation training.
        Surg Endosc. 2021; https://doi.org/10.1007/s00464-021-08602-y
        • Stucky CH
        • De Jong MJ
        • Kabo FW.
        Military surgical team communication: Implications for safety.
        Mil Med. 2020; 185: e448-e456https://doi.org/10.1093/milmed/usz330
        • Stucky CH
        • De Jong MJ
        • Kabo FW
        • Kasper CE.
        A network analysis of perioperative communication patterns.
        AORN J. 2020; 111: 627-641https://doi.org/10.1002/aorn.13044
        • Stucky CH
        • De Jong MJ.
        Surgical team familiarity: An integrative review.
        AORN J. 2021; 113: 64-75https://doi.org/10.1002/aorn.13281