Operating Room Fire Malpractice Prevention Initiative Launched by FDA

Donald Saiontz

By Donald Saiontz
Posted December 14, 2011


The FDA has launched a new initiative designed to prevent surgical fires in operating rooms throughout the United States. These rare incidents can have devastating consequences for the patient and in many cases they are caused by medical mistakes during surgery, which can be prevented.   

The new Preventing Surgical Fires Initiative was launched with the goal of increasing awareness about the causes of operating room fires, disseminating prevention tools and promoting practices that reduce the risk of surgical fires occurring. The FDA has released a video on how fires start in operating rooms and how to prevent them, recommendations for healthcare professionals and information for patients.

According to the FDA, an estimated 550 to 650 surgical fires occur every year in the United States, despite the fact that the causes are well-understood and often preventable. These fires can cause serious burns, disfigurement and deaths.

Surgical fires typically occur when there is a high concentration of oxygen in the operating room. The greatest risk of fires comes from open oxygen delivery systems, like nasal cannula or masks. These devices also present a higher risk to the patient, as most deaths occur when fire in the patient’s airway is ignited. Closed delivery systems, like a laryngeal mask, present less of a threat of fire. Materials that would not normally burn may catch fire in oxygen-rich environments.

For an operating room fire to start, there also needs to be an ignition source, like a laser or fiber optic light, and a fuel source, such as surgical drapes or alcohol-based products. In some cases, the patient’s body is the fuel source.

The FDA has issued a list of recommendations that the agency believes can help prevent surgical fires. A fire risk assessment should be conducted before each procedure, the FDA said, with procedures that involve supplemental oxygen and operation of an ignition source near the oxygen considered the highest risk procedures.

Healthcare professionals have been urged to use supplemental oxygen safely by first evaluating whether supplemental oxygen is necessary. If it is, then they should deliver the minimum concentration needed to provide adequate oxygen to the patient.

The FDA also recommended that healthcare professionals use a closed oxygen delivery system whenever possible, especially if high concentrations of supplemental oxygen are needed. Additional precautions can be taken by applying techniques that prevent oxygen from building up in the operating area.

Another means of preventing surgical fires is the safe use of alcohol-based skin preparations and surgical equipment. Healthcare professionals should prevent alcohol-based antiseptics from pooling, remove alcohol-soaked materials from the prep area and allow the skin to dry adequately and making sure it is dry before surgery. Healthcare professionals should also try to use alternative surgical devices when a procedure calls for the use of a possible ignition source, like a laser, near a supplemental oxygen supply. They should also never place ignition sources on the patient or drapes and should instead use a holster, keep good communication among the surgical team and anesthesia professional about the use and location of ignition sources and oxygen, and have a surgical fire management plan in place.

The FDA is partnering with several medical organizations to help spread word of the initiative, including the American Association of Nurse Anesthetists, the American Society of Anesthesiologists, the American Society for Healthcare Engineering, the American Society of PeriAnesthesia Nurses, the Institute for Safe Medication Practices and others.


Through the exercise of the proper standards of medical care, operating room problems can often be prevented. As a result, individuals who have suffered serious or fatal injuries as a result of a surgery fire may be able to pursue financial compensation through a medical malpractice lawsuit.

To review a potential case for yourself, a friend or family member, request a free consultation and claim evaluation.

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