Fanning the flames of surgical fire prevention

http://www.hpnonline.com/inside/2008-05/0805-OR-Fire.html
Tuesday, November 03, 2009 6:38:35 AM
by Susan Cantrell, ELS

Shout "Fire!" and it’s sure to grab the attention of everyone in hearing distance.
Maybe the last place you’d want to hear that is as you’re sailing into LaLa Land
while a surgeon hovers over you wielding an electrosurgical tool close to your
tender parts. It’s a scary—make that terrifying—thought, but unfortunately it does
happen.

Possible but not probable

Mark Bruley, vice president, accident and forensic investigation, ECRI Institute,
Plymouth Meeting, PA, told Healthcare Purchasing News that fire in the operating
room (OR) is one of three "never" events, the other two being wrong-site surgery
and leaving an instrument in the patient. Obviously these are things that can be
prevented and so should n-e-v-e-r happen to a patient. These are the sorts of
incidents for which Medicare will soon discontinue reimbursing.

Fortunately, surgical fires don’t happen as often as you might think. Bruley noted
that figures published in September 2007 by the Pennsylvania Patient Safety
Reporting System cite the chance of a surgical fire in Pennsylvania as being 1 in
87,646 operations, with an average of 28 per year. Extrapolating those numbers to
the entire United States, the number of fires occurring nationally ranges from 550 to
650. That’s not good, but it’s not much when balanced against the 50 million
inpatient and outpatient surgeries performed each year nationally. Even better
news is that 80% to 90% of the fires are minor, resulting in no injury. In only 10 to
20 cases per year are victims of surgical fires seriously burned or disfigured. That’s
seldom enough to deem surgical fires as being rare, claimed Bruley.

Are surgical fires on the rise, or are we just hearing about them more? Roger Odell,
co-founder, chairman, and director of Encision Inc, Boulder, CO, believes there
really is no way to know the answer. "Only 1% to 2% of complications, including
death, are reported to the FDA. The data base is flawed." Melissa K. Fischer, RN,
BSN, CNOR, clinical specialist, Megadyne Medical Products, Draper, UT, added:
"Statistics do not demonstrate that OR fires are on the rise, but there is more
awareness of the problem and better reporting of smaller incidents."

On the rise or not, fire in the OR is definitely getting more attention, according to
Bruley. "Increased attention to surgical fires started in 1999 with the release of the
Institute of Medicine study on medical errors, ‘To Err Is Human: Building a Safer
Health System.’ I think fewer fires are happening now, but they’re getting more
attention because it’s more culturally acceptable to talk about medical error now."