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The Joint Commission issues Sentinel Event Alert on surgical fire prevention

Alert warns of fire danger and provides recommendations to prevent fires during surgery Wednesday, October 18, 2023

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Maureen Lyons
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(OAKBROOK TERRACE, Illinois, October 18, 2023) – Best estimates suggest that 90 to 100 surgical fires occur annually in the United States, creating safety hazards for patients, surgical teams and the operating room (OR) environment. Specifically, most surgical fires and burns are associated with the use of an electrosurgical device while performing head and neck surgery.

The Joint Commission has issued Sentinel Event Alert, “Updated surgical fire prevention for the 21st century” to alert surgical teams to risk factors for surgical fires and to help identify strategies and actions to prevent them.

Sentinel event data compiled by The Joint Commission suggest that leading factors contributing to surgical fires include shortcomings in teamwork and communication, work design, workforce and staff, and equipment. According to the Sentinel Event Alert, to overcome these shortcomings and reduce occurrences of surgical fires, staff should mind elements of the “fire triangle”: 1) oxygen, 2) ignition sources and 3) fuel.

The Sentinel Event Alert suggests the following actions to prevent surgical fires: 

  1. Ensure that the pre-surgery time-out includes a robust fire risk assessment for each surgical and endoscopic procedure.
  2. Anesthesiologists should maintain the local oxygen concentration at less than 30%, whenever possible.
  3. Carefully manage electrosurgical devices, light sources and cables, surgical draping, and other risks during a procedure.
  4. Provide training to operating room staff on how to avoid and manage fires and conduct fire drills.
  5. Report all surgical fires into your facility’s incident reporting system.
  6. Educate all OR personnel/team members about the risk of surgical fires.

“Surgical fires can spark and quickly cause significant harm to patients, providers and the surgical environment,” says Herman A. McKenzie, MBA, CHSP, director, Physical Environment Department, Standards Interpretation Group, The Joint Commission. “Care must be taken, especially when using electrosurgical tools, to reduce the risk of fires. Recommendations in the Sentinel Event Alert, as well as The Joint Commission’s relevant requirements on fire prevention within the surgical environment, can support healthcare organizations as they develop fire prevention policies and procedures.”

The Sentinel Event Alert also reviews related Joint Commission requirements and provides resources and references. The full alert is available on The Joint Commission and The Joint Commission Journal on Quality and Patient Safety websites. It may be reproduced if credited to The Joint Commission.


About The Joint Commission

Founded in 1951, The Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission accredits and certifies more than 22,000 health care organizations and programs in the United States. An independent, nonprofit organization, The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in health care. Learn more about The Joint Commission at