Surgical Fires: 100% Preventable, Still a Problem

Watson, Donna S.

doi:10.1016/j.aorn.2009.09.012

Cited by 12 publications

(12 citation statements)

References 1 publication

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“…Airway fires were also an infrequent complication (2.8%). This is due most likely to the recent increased vigilance of anesthesia, surgeon, and operating room staff in preventing surgical fires over the last several years 21–23…”

Section: Discussionmentioning

confidence: 99%

Complications and legal outcomes of tonsillectomy malpractice claims

Stevenson

Myer

Shuler³

et al. 2011

The Laryngoscope

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Tonsillectomy carries a large amount of risk from a malpractice standpoint. Postoperative bleeding is the complication most commonly associated with malpractice claims, but may not carry the greatest overall risk from a patient care or monetary standpoint. Hypoxic and anoxic events, although less common, appear to carry more morbidity for the patient and are associated with greater settlements and judgments in malpractice claims. Tonsillectomy continues to carry a significant mortality risk, albeit infrequent, and a high level of vigilance should be employed to help reduce these risks.

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Section: Discussionmentioning

confidence: 99%

Complications and legal outcomes of tonsillectomy malpractice claims

Stevenson

Myer

Shuler³

et al. 2011

The Laryngoscope

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“…The alcohol content in this skin prep agent is an undesirable catalyst in the OR because of its flammability 1,3 . Along with specific SSIs, surgical fires are considered “never events” (ie, preventable events that may cause serious injury or death) by the Centers for Medicare and Medicaid Services and are considered 100% preventable 9,25 . An overview of the advantages and disadvantages of the prep agents included in this literature review is provided in Table 2.…”

Section: Resultsmentioning

confidence: 99%

“…Ignition sources (eg, electrosurgery, lasers) are used commonly in surgery; therefore, the potential of a surgical fire is increased any time alcohol-based or flammable skin prep agents are used. 25,26 According to a 2009 ECRI Institute guidance report, 70% of surgical fires are caused by an electrosurgery unit and 10% are related to laser use, both of which are common ignition sources in any OR setting. 26 Furthermore, surgical fires rank third on the ECRI Institute's technology hazard alerts.…”

Section: Discussionmentioning

confidence: 99%

Intraoperative Patient Skin Prep Agents: Is There a Difference?

Zinn¹,

Jenkins²,

Swofford³

et al. 2010

AORN Journal

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For health care institutions, intraoperative prep agents are a critical link in combating surgical site infections and the associated economic burden. The question remains, is there an intraoperative prep agent that is truly superior to the others? We conducted a literature review to examine available empirical evidence related to intraoperative prep agents used in our health system for open abdominal, general surgery procedures: povidone-iodine, chlorhexidine gluconate, parachoroxylenol, and iodine povacrylex in 74% isopropyl alcohol. Intraoperative surgical skin prep studies were limited in providing empirical evidence to support one superior prep agent. Each prep agent has a specific mechanism of action along with specific advantages and disadvantages. We concluded that no one perioperative skin prep agent is superior in all clinical situations. Factors to consider when choosing an appropriate intraoperative skin prep agent include contraindications, environmental risks, the patient's allergies and skin condition, the surgical site, the manufacturer recommendations for the prep agent, and surgeon preference.

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“…7 These complications include severe burns; extended lengths of hospital stay; prolonged postoperative and long-term care; substantial deformity; and, frequently, the necessity of additional surgeries. 8 Three elements are needed for a fire to occur in the OR setting: an oxidizer, an ignition source, and a source of fuel (ie, the fire triangle). One to two patients die every year as a result of surgical fires, primarily airway fires.…”

Section: Simulated Surgical Firesmentioning

confidence: 99%

“…18 It is triggered by medications that are typically used in anesthesia, with inhalational anesthetics and succinylcholine being the most commonly implicated triggering agents. 8 This is a true emergency in the OR, and mishandling it can result in the patient's death. 8 This is a true emergency in the OR, and mishandling it can result in the patient's death.…”

Section: Simulated Malignant Hyperthermiamentioning

confidence: 99%

Using Simulation Training to Improve Perioperative Patient Safety

Mullen¹,

Byrd²

2013

AORN Journal

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Simulation learning provides medical and nursing personnel with the opportunity to develop and refine their skills without putting patients at risk. Faced with ensuring the competence of a large number of new staff members, the management team at one facility implemented a simulation training program. Surgical team members are able to participate in an ongoing program of simulated scenarios involving surgical drape fires and airway fires, cardiac arrest of patients in the supine position and prone position, respiratory depression in the postanesthesia care unit, and malignant hyperthermia. The simulations help OR staff members identify problems that can happen during real emergencies and help them work as a team to prepare for events that may represent life-threatening situations for patients.

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Surgical Fires: 100% Preventable, Still a Problem

Cited by 12 publications

References 1 publication

Complications and legal outcomes of tonsillectomy malpractice claims

Complications and legal outcomes of tonsillectomy malpractice claims

Intraoperative Patient Skin Prep Agents: Is There a Difference?

Using Simulation Training to Improve Perioperative Patient Safety

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