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Fires occur on a daily basis throughout this country, most occurring in the home. The National Fire Protection Association (NFPA) reports that there were 395,500 reported home fires in 2004. In addition, there are countless fires that occur both in homes as well and elsewhere that go unreported.

How many times have you shut the lid on your own barbeque grill and shut off the gas supply to extinguish a grease fire? Did you pick up your cell phone and call the fire department to report the fire? No. Minor fires like this occur every day and in most circumstances are controlled by the homeowner. These fires, however minor, go unreported to the local fire department. Therefore, the report data generated by the National Fire Incident Reporting System (NFIRS) system doesn’t accurately reflect the total number of fires that have occurred on a daily basis throughout this country. Likewise, we also must wonder how accurate the hospital operating room (OR) fire data is that lists anywhere from 108 to 200 fires per year in the surgical setting.   

In the realm of safety professionals, we define a “near-miss” as an unintentional incident or event that doesn’t result in injury and/or property damage. If a surgical fire occurs in the hospital setting, it can be further complicated because the incident occurred in what we might term a “closed setting” (i.e. a group of medical professionals from many different disciplines working together daily as a team). These types of close knit groups rarely want to discuss the actions of colleagues in an untoward event, particularly if it means the report will lead to an internal investigation done by an “outsider” (e.g.; risk management). 

If you don’t agree, ask yourself the following question: Could this incident occur at my hospital or ambulatory surgical center? A distracted surgeon accidentally steps on the footswitch to an unholstered laser; it activates and momentarily fires a concentrated beam of light into a surgical drape. The surgeon realizes his mistake and slips his foot off of the footswitch but a small circular burn patch has already begun to develop. The drape is quickly knocked to the floor by the surgical technician and extinguished when the circulating nurse douses it with sterile water. The surgical team responded immediately and appropriately, the patient was anesthetized at the time, nobody including the patient was harmed and the fire was incidental. Everybody looks at each other from behind their surgical masks with the same thought: “We have a long schedule today and nobody else needs to know what just happened.” Later, they might discuss the incident among themselves, but it never gets passed along. They believe it probably doesn’t warrant a report, so it doesn’t make it into the hospital’s risk management incident reporting system, and it certainly doesn’t get reported to the local fire department.    

I would suggest that the number of reported surgical fires is much like viewing an iceberg floating in the ocean. Yes, we see the small number above the waterline but we don’t see the bigger danger below. A large number of unreported surgical fires and an even greater number of surgical fire near-misses are located just under the waterline. These unreported surgical fires and near-misses are potentially hazardous and could lead to a serious incident, but they are hidden from our view.  

We often don’t see the problem because it is not reported, and some of us may take the attitude that it hasn’t happened here before, so what’s the problem? The JCAHO Sentinel Event Alert, Issue 29, June 2003 “Preventing Surgical Fires” probably sparked initial interest and a flurry of training at the hospital, but we have since become apathetic. If we operate an ambulatory care center and are JCAHO accredited, we have a heightened sense of awareness because of the 2005 National Patient Safety Goal #11 to “Reduce the risk of surgical fires.” Those of us who have read the suggested ECRI surgical fire safety guidelines and AORN Guidance Documents understand the potential risks involved with surgical fires. However, we can be conflicted and constrained by a multitude of issues, such as staffing, administration, workload, time, budget and our own meeting processes.   

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