The Joint Commission just updated its surgical fire prevention guide for the first time in twenty years. This doesn’t come as a total surprise. The Joint Commission has been getting serious about surgical fire safety all year. In April they published a safety advisory on preventing light source burns. In August they published a survey of perioperative nurses’ experiences with surgical fires.
The message is clear; it’s time to take a proactive and preventive approach to fire safety in your ORs. Here’s what you need to know from The Joint Commission’s new Sentinel Event Alert.
Understand and Consider the Elements of the Fire Triangle
In a recent incident, an otherwise healthy patient undergoing a minor procedure experienced a surgical fire. The use of electrocautery, an alcohol-based skin preparation, and the administration of oxygen through a nasal cannula created the perfect storm. A flash ignited, resulting in a fire that, despite being promptly extinguished, left the patient with second-degree burns on the face. The aftermath necessitated a transfer to the burn unit and eventual reconstructive plastic surgery.
To address the complexity of surgical fires, it’s crucial to understand the elements of the fire triangle—oxygen, ignition sources, and fuel. The case study highlights how the use of an electrosurgical device (ignition source), alcohol-based skin preparation (fuel), and the administration of oxygen (oxidizer) converged to create a hazardous situation.
Establish Standardized Reporting Procedures
Surgical fires are not isolated incidents; they persist as a significant risk within healthcare. The Joint Commission sheds light on the prevalence of these events, estimating that 90 to 100 surgical fires occur annually in the United States. The true extent, however, is likely unknown due to underreporting because of factors such as embarrassment, fear of adverse publicity, or potential legal repercussions. The Joint Commission recently published survey results where 1 in 3 perioperative nurses reported having witnessed a fire or burn within the past year.
Creating a culture of safety is imperative to prevent surgical fires. Encourage open communication about safety concerns, including near misses, conduct regular safety training sessions, and recognize and reward employees who contribute to a safer workplace.
The Joint Commission Requirements
Joint Commission Environment of Care requires accredited organization to adhere to the following:
- Periodically evaluate potential fire hazards that could be encountered during operative or invasive procedures.
- Establish written fire prevention and response procedures, including safety precautions related to the use of flammable germicides or antiseptics.
- Manage risks related to hazardous materials and waste.
- Mandate fire drills
- Collect information to monitor conditions in the environment, and, at least annually, review each environment of care management plan’s objectives, scope, performance, and effectiveness.
Take A Proactive Approach
The Joint Commission offers actionable and specific strategies to mitigate the risk of surgical fires:
- Comprehensive Fire Risk Assessment: Conduct a robust fire risk assessment before each surgical procedure. Evaluate all supplies and equipment, inspect for working order, and assess the environment for potential ignition sources, fuel, and oxygen.
- Oxygen Management: Maintain oxygen concentration below 30%, whenever possible. Consider alternatives like endotracheal tubes or laryngeal mask airways if higher oxygen levels are clinically indicated.
- Careful Management of Devices: Handle electrosurgical devices, light sources, cords, and drapes with caution. Avoid using electrosurgical devices in the trachea or bowel, use the lowest power setting on devices, and place active devices in nonconductive holsters when not in use. For light sources and cords, place the light source in standby mode and disconnect the light cord from the light source. The Joint Commission also suggests placing protective covers/caps (like GloShield) over the cord before use.
- Continuous Hazard Assessment: Continuously assess hazards during surgery, configure drapes for optimal oxygen flow, and identify patients with higher gas production. Encourage a culture of open communication and immediate reporting of potential risks.
The prevention of surgical fires requires a collective commitment from every member of the surgical team. By understanding the elements of the fire triangle, implementing stringent protocols, and fostering a culture of continuous improvement, healthcare organizations can keep patients and staff safe by preventing surgical fires. For more specifics, be sure to check out The Joint Commissions’ Sentinel Event Alert and contact us to learn more about how GloShield can be an integral part of your fire prevention strategy.