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Operating room fires make the top 10 list of 2020 hospital sentinel/never events

Most OR fires include oxygen and either electrocautery or lasers

When The Joint Commission, a healthcare accrediting agency, recently released its report on 2020 hospital and healthcare facility sentinel events (also called never events because they’re never supposed to occur, but somehow still do), fire was among on the list of the 10 most common ones.

I bet most people thing of a building up in flames when the word fire comes to mind. While that certainly can happen in hospitals, ambulatory care facilities, outpatient surgery centers, and imaging centers, sprinkler systems and other fire protection measures have a general handle on them. What’s more common, though, in a healthcare setting is a fire occurring during operating room (OR) care of a patient.

In OR settings, there are multiple ingredients, if you will, being used in close proximity to one another at play that can lead to an accidental fire—heat (lasers), friction, oxygen, anesthetic gases, and flammable surgical drapes.

When considering fire risk, experts refer to the fire triad of oxidizer, fuel, and ignition source. Thus, to prevent operating room fires, hospital and surgery center leaders need to implement policies, procedures, and training to reduce each component contributing to accidental fires.

Closed claim studies have shown that electrocautery fires are common during head, neck, and upper chest surgical procedures, with oxygen being the oxidizer for nearly 100% of all fires. Anesthesiologists and certified registered nurse anesthetists (CRNAs) consider face, head, neck, shoulder, and airway surgeries under monitored anesthesia to pose a high risk for an operating room fire and burn injury. Other research has established that nearly every operating room (OR) fire case involves electrocautery or laser use in conjunction with oxygen administration.

Fire prevention requires constant vigilance by operating room personnel and, in particular anesthesia providers. Even a momentary distraction or poor choice can lead to a disaster.

In one OR burn case, a jury found an anesthesiologist and her practice primarily responsible for horrific burn injuries that left a middle-aged woman with a permanent tracheostomy, feeding tube, and admission to a long-term care facility.

What happened?

The patient sought surgical treatment because of a hoarse voice following a lengthy intubation (breathing tube placement) from a previous surgery. She was taken to the OR for removal of a vocal cord polyp. In the hands of a trained surgeon, that’s simple enough.

The anesthesiologist intubated the patient and started her on 100% oxygen, and then turned away to do some paperwork as the surgeon began the laser procedure. Almost instantly, there was a loud pop and the OR team recognized and responded to the fire. The patient experienced fire/thermal burns and was left with a ravaged trachea, vocal cords, and esophagus. The jury found that the fire and injuries would’ve been avoided if the anesthesiologist had been vigilant and paying attention.

If you’ve been seriously injured by an operating room fire in Texas, then contact a top-rated experienced medical malpractice lawyer for a free consultation about your potential case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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