Surgical Fire Prevention in Healthcare Facilities

If asked how often fires occur during surgery, most healthcare professionals would probably be of the opinion that these situations are extremely rare. However, the truth is that surgical fires occur fairly often. In fact, it is estimated that between 550 and 650 surgical fires occur in the United States every year.

There are a number of common causes of surgical fires. Seventy percent of them are ignited by electrocautery devices. Twenty percent start because of light sources, wires, and defibrillators. And 10% are started by lasers.

While surgical fires mainly occur in hospitals, they can happen anywhere – including ambulatory surgery centers and physician offices. Furthermore, these fires most commonly occur in the head, neck, and chest area during those types of surgeries.

So what can we do to help prevent surgical fires from happening? According to Caroline Stegeman – who serves as a senior patient safety consultant at LHA Trust Funds – we begin by focusing on three factors. First, identify the locations and types of procedures where surgical fires commonly occur. Second, identify the three components of the “fire triangle.” And third, institute best practices for surgical fire interventions.

“Surgical fires occur in, on, or around a patient who is undergoing a medical or surgical procedure,” Caroline says. “Unfortunately, they are underreported. However, since we know the root causes of these fires, we can take steps to help prevent them.”

Some surgeries pose a higher risk of surgical fires than others. These surgeries include procedures that are performed above the xiphoid process and in the oropharynx that carry the greatest risk: T&As, traches, removal of a laryngeal papilloma, burr hole surgeries, and any lesions removed on the head, face, and neck. The reason why these are at high risk for surgical fires is that anesthesiologists or CRNAs can have a tendency to give patients more oxygen than necessary.

So exactly how do surgical fires happen? We can help to explain this by discussing the “fire triangle,” which consists of three elements: the ignition source, fuel source, and oxidizer. These elements exist in almost every surgical situation. When you visualize this triangle, imagine the patient being right in the middle of these three elements. Now let’s take a closer look at each element.

Ignition Sources

This includes anything in the O.R. that can spark a fire (which can occur wherever oxygen and a fuel source are present). Ignition sources include overhead surgical lights, defibrillators, electrosurgical or electrocautery units, heated probes, power tools, drills or burs, fiber-optic light sources and cables, lasers, magnets, and MRI machines. Other sources include overheated IV solutions or blankets that are warmed in heating cabinets.

Fuel Sources

This includes anything that is flammable. Remember that almost everything that comes in contact with a patient in the O.R. is a potential fuel source – and the patient is also considered a fuel source. Examples of fuel sources include prep solutions, sponges, drapes, towels, hoods, masks, anesthesia circuits, dressings, and ointments. Even the patient's hair (both on the head and body) is a fuel source – along with the patient’s tissue and GI content.


Oxidizers are supplied by the anesthesiologist or the CRNA. They monitor the amount of oxygen given to the patient. It is important to minimize the amount of oxygen used to reduce the risk of fire. Also, the standard procedure is that if more oxygen is needed, it’s vital to secure the airway and mask placed over the airway and prevent oxygen from venting under the drapes.

Now that we’ve covered the fire triangle and the risks involved, let’s focus on some best practices. First it must be understood that fire prevention is a team effort. It includes all surgical team members, from the physician to the anesthesiologist delivering the medical gases, the surgeon controlling the ignition source, the O.R. staff applying the skin prep agents and drapes, and any additional staff that may be in the room.

The first step is to conduct a surgical fire risk assessment prior to surgery on all patients – whether they're having surgery on their face or on their foot. You need to be aware of high-risk procedures, any possible ignition sources, the delivery of supplemental oxygen – you really need to be aware of any use of an ignition source near the oxygen. If it turns out that your fire risk assessment score is three or greater, you need to implement high-risk prevention measures. If it's under two, implement routine measures.

“The team then needs to discuss how a fire will be prevented – and what to do if a fire occurs,” Caroline says. “All of this discussion needs to occur in the Time Out process for every patient and you need to ensure that you document this in your EMR.”

The following are several more specific best practices:

Safe Use of Oxidizers – You should titrate to the minimum concentration and use the closed oxygen delivery system if possible. If using an open system, exclude oxygen and flammable/combustible gases from the O.R. field. Tent the drapes to allow for free airflow and also evacuate any surgical smoke from small or enclosed spaces. Most importantly, turn off the O2 at the end of each procedure.

Safe Use of Ignition Sources – Consider alternatives to using an ignition source for high-risk surgeries if you're delivering high concentrations of supplemental oxygen. If using an ignition source, allow time for the oxygen concentration to decrease in the O.R. area. Do not allow an ignition source to enter the bowel when it is distended with gas. And you also want to inspect all instruments for evidence of insulation failure.

Other best practices quick tips include:
• Do not activate electrosurgical units when near or in contact with other instruments.
• Keep tips of cautery instruments clean and free of char and tissue.
• When not in use, keep instruments in a designated area away from patients.
• Use water-based ointments on patients’ hair (head or body).
• Prevent pooling of skin prep solutions.
• Beware of ANY items in the O.R. that may be fuel sources (drapes, towels, sponges, gauze, ET tubes, laryngeal mask, suction catheters, etc.).

Other ways to promote surgical fire prevention include conducting education and drills at least annually – as well as for new employees. You also should make sure that surgical suites and procedure areas have appropriate firefighting equipment and that staff members know where to find it and how to use it properly.

“In order to increase surgical fire safety it’s also important to promote a culture that allows all surgical team members to speak up,” Caroline says. “Everyone must feel comfortable in pointing out potential problems without fear of retaliation or punishment.”

While surgical fires are not the most common type of risk in the healthcare environment, they can be devastating to both the patient and medical staff members when they do occur. That’s why it’s vital to take the steps necessary to prevent these fires from ever happening at your facility.

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