Surgical fires are rare. In fact, they are so rare that patient safety groups have deemed them to be “Never Events” – meaning that they should never happen.
Learn More About Never Events
When fires in the operating room do occur, they cause unspeakable trauma and suffering. In the United States alone, more than 650 operating room fires are reported each and every year. Why are surgical fires occurring and what can be done to prevent them?
A recent review of 54 cases of surgical fires and burns found that many people were left with scarring, disfigurement, and trauma as a result of those fires. One third of these cases occurred in the operating room and involved some type of burn from surgical equipment or from chemicals that were used during the surgical process. Some patients caught fire because of the alcohol-based products used to clean and prep the skin. Others caught fire because the anesthesiologist used 100% oxygen instead of the lowest possible concentration.
When a Surgical Fire Constitutes Medical Malpractice
A “never event” should literally never occur. As such, the majority of surgical fires are the result of medical malpractice. How does medical malpractice lead to a surgical fire? Here are some examples:
- Skin preps not being allowed to dry properly;
- Alcohol solutions allowed to pool under the patient;
- Use of 100% oxygen;
- Sparks from cauterizing tools or lasers igniting dry gauze pads or sponges inside an incision site;
- Equipment malfunction;
- Laser power level set too high;
- Communication breakdown; and
- Delays in diagnosing burns.
A review of the events found that half of the fires occurred because the oxygen concentration was too high during laser surgery to the head, neck, or upper chest. Some errors came down to human factors and were the result of doctors, nurses, or anesthesiologists not following proper O.R. Protocols.
Surgical Fires Can Cause Devastating Injuries
Many of the surgical fires reported occurred when the endotracheal tube cuff caught fire because of the use of too much oxygen. Recently, a Seattle woman was awarded $30 million in damages when her endotracheal tube caught fire inside of her throat. She was undergoing surgery for polyps on her vocal chords and a fire ensued. The damage she sustained because of the fire in her throat has made it impossible for her to speak or even to breathe on her own.
How Can Surgical Fires be Prevented?
A surgical fire can occur any time the three elements of the “Fire Triangle” are present in the operating room (ignition source, fuel source, and oxygen). The ECRI analyzed numerous surgical fire case reports and found that the most common ignition sources were electrosurgical equipment (68%) and lasers (13%). In general, the surgeon controls the ignition sources.
Nurses in the operating room control the fuel source, with the most common fuel sources being preparation solutions, drapes, sponges, and masks. If the drapes are placed in such a way that allows for oxygen to pool underneath them or if dry gauze pads are used instead of wet gauze pads, then a fire can occur more easily.
The anesthesiologist controls the oxygen flow to the patient during the operation. Anesthesiologists should try to reduce the amount of oxygen they use to prevent fires from occurring.
In 2011, the U.S. Food and Drug Administration began a surgical fire prevention initiative. According to documentation associated with that initiative, there are numerous ways that surgeons, anesthesiologists, and medical personnel can reduce the likelihood of a surgical fire. Good communication, of course, is key, but other ways to reduce surgical fires include:
- Wait 3 minutes for alcohol prep to dry and fumes to evaporate before using electrosurgical units (ESU);
- Always use the ESU safety holster;
- Never lay hot light cables on drapes;
- Reduce O2 requirements to 30%;
- Eliminate pooling of prep solutions;
- Use wet sponges and towels on the surgical field;
- Follow appropriate laser safety policies; and
- Use saline to minimize sparking.
Contact Our Pennsylvania Medical Malpractice Lawyers Today
The medical malpractice attorneys at McLaughlin & Lauricella, P.C., have more than 100 years of experience representing injured patients and their families across Philadelphia, Berks, Bucks, Dauphin, Delaware, Lackawanna, Lehigh, Luzerne, Montgomery, and Northampton Counties. We are also proud to serve injured patients and families throughout the State of New Jersey. Contact us today at (855-MED-MAL1), or fill out our confidential contact form to learn more about your legal options.
