You know sometimes you read a story and you just can’t believe it? This was one of those that I read on MSN. Did you know that between 550 – 650 people actually catch fire in the operating room each year?
Although it is a rare occurence, apparently hospitals have not been required to report them to the FDA. It was only through an extensive review of medical errors in Pennsylvania (where hospitals are required to report such incidents) that researchers were able to estimate the problem across the country.
The potential for a fire in the OR exists because of combination of conditions: the use of electrosurgical instruments (such as a Bovie used to stop bleeding), the pure oxygen being supplied to the patient and the disposable thin hospital drapes. With these three things you have all the elements required for a fire: heat, air and fuel.
As one would imagine, a fire is certainly preventable. Mark Bruley, vice president of accident and forensic investigations at the ECRI Institute, a patient safety advocacy agency, has said that he has been trying for years to promote more communication between the surgeon and the anesthesiologist and has had limited success.
“If a surgeon is getting ready to use an electro cardio pencil and he has not been informed that oxygen is flowing under the drapes, the result could be a fire,” Bruley said. “Oxygen concentrations of 50 percent and higher will create a flash fire.”
While Bruley feels no additional reporting requirements specific to fires is needed, he does believe that additional education is the answer to preventing patients from catching fire in the operating room. He ” is working now on a Web-based training program that will bring the basics of fire prevention to even the most remote hospitals and care centers.”