New Sentinel Event Alert focuses on preventing surgical fires

Editor's Note

A new Sentinel Event Alert from The Joint Commission focuses on the continuing dangers of surgical fires, why they occur, and how to take preventative measures. The alert was issued on October 18.

Some highlights include:

• There is no national repository collecting data on surgical fires, and little reliable data. 
• The independent nonprofit ECRI estimates that there are 90 to 100 surgical fires each year in the US.
• Leading factors contributing to surgical fires include shortcomings in teamwork and communication, insufficient time to assess the risk or perform safeguards, risky behavior, equipment malfunction, and lack of training related to OR equipment.
• Surgical fires are also associated with use of 100% alcohol, use of 100% oxygen, and failure to use proper precautions with electrosurgical devices.

The alert notes that the majority of surgical fires and burns are associated with the use of an electrosurgical device while performing head and neck surgery.