Sentinel Event Alert 29: Preventing surgical fires

In the fire triangle—heat, fuel and oxygen—each element must be present for a fire to start. And, though the incidents are significantly under-reported, too often all three elements come together in a hospital's surgical suite, yielding disastrous consequences. Though they are considered rare occurrences in the health care environment, surgical* fires are certainly one of the most frightening and devastating experiences for everyone involved. While exact numbers are not available, of the more than 23 million inpatient surgeries and 27 million outpatient surgeries, performed each year, estimates—based on data from the Food and Drug Administration (FDA) and ECRI, an independent nonprofit health services research agency—indicate that there are approximately 100 surgical fires each year, resulting in up to 20 serious injuries and one or two patient deaths annually.