Preventing Surgical Fires: Important New Recommendations Released By ECRI Institute

ECRI Institute and Anesthesia Patient Safety Foundation Offer Resources for Reducing Fire Risk

surgical-firePLYMOUTH MEETING, A flash fire on a patient during surgery is a very real tragedy, often leading to disfigurement, disability or even death. Though surgical fires are uncommon—about 550 to 650 occur in the United States each year—their consequences are grave enough to warrant ongoing prevention education by healthcare providers.

For this reason, ECRI Institute® (, an independent nonprofit that researches the best approaches to improving patient care, in collaboration with the Anesthesia Patient Safety Foundation (APSF), released important changes to its recommendations for preventing surgical fires. The changes are detailed in the article, “New Clinical Guide to Surgical Fire Prevention,” featured in ECRI Institute’s October issue of Health Devices, a monthly journal featuring independent, comparative evaluations of medical devices and systems, as well as in-depth technology guidance.

Most importantly, the organization’s recommendations focus on eliminating the traditional practice of open delivery of 100% oxygen during sedation. Securing the airway is recommended if the patient requires an increased oxygen concentration.

Mark-Bruley-ecri“As the oxygen concentration increases in an area, so will the risk of fire,” explains Mark Bruley, BS, CCE, vice president, accident and forensic investigation, ECRI Institute. “Fires in oxygen-enriched atmospheres ignite much more easily, burn hotter and spread more quickly. The goal is to stop open oxygen delivery for surgery around the head and upper chest. For exceptional cases, which are detailed in the new guidance, delivery of the minimum concentration of oxygen necessary to maintain adequate blood oxygen saturation is recommended.”

The updated report comes at a time when many hospitals and healthcare groups, the Joint Commission, and professional societies are taking extra steps to prevent surgical fires. New recommendations for oxygen delivery during surgery are detailed in the Health Devices article. Also included is additional guidance for avoiding surgical fires, and how to respond if a fire occurs.

“ECRI Institute’s much-needed and updated guidance on surgical fires can serve as a valuable educational reference for all those who work in the operating room, especially in dispelling misconceptions regarding fire safety and by specifically recommending reducing concentrations in the open delivery of oxidizers,” says Charles Cowles, MD, anesthesiologist and chief safety officer, University of Texas, MD Anderson Cancer Center, Houston. “ECRI Institute has done an excellent job educating the surgical staff on how to reduce or eliminate these truly preventable incidents.

Additional fire safety resources available through ECRI Institute include its new Surgical Fires Prevention Web site: . The site offers links to a surgical fire prevention poster for the operating room, available for free download or purchase; a downloadable poster with steps for extinguishing a surgical fire; and contact information for immediate confidential assistance for facilities that require accident investigation.

Also, ECRI Institute and APSF are producing a new surgical fire educational video to be released in late 2009 and developing an online course with continuing medical education credits to be available in early 2010.

For more than 40 years, ECRI Institute’s Accident and Forensic Investigation Group has assisted healthcare facilities in determining the cause of incidents, injuries and deaths, and preventing future accidents. The group helps organizations react quickly, maintain operations, and restore confidence after a medical device or medical care harms rather than helps.

The Health Devices journal is provided to members of ECRI Institute’s Health Devices System, Health Devices Gold, and SELECTplus™ programs. Health Devices features comparative, brand-name evaluations of medical devices and systems based on extensive laboratory testing and clinical studies. ECRI Institute’s evaluations focus on the safety, performance, efficacy, and human factors design of specific medical devices and technologies.

The October 2009 issue of Health Devices and the poster, “Only You Can Prevent Surgical Fires,” are available for purchase online at For information about membership in the Health Devices System, contact ECRI Institute by mail at 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA; by telephone at (610) 825-6000, ext. 5891; by e-mail at; or by fax at (610) 834-1275.