Safety & Security
Page 2
One of the problems with identifying the real surgical fire problem is that there is no centralized database to capture the actual number of surgical fires. \No one has established a national surgical fire toll-free hotline or Web site on which individuals could report near-misses and remain anonymous. In an article entitled “Danger from OR Fire Still a Serious Problem” Dr. Wolf, Professor of Anesthesiology, at the State University of New York Health Science Center in Brooklyn, NY, estimates that only one to ten percent of OR fires are reported. The exact incidence is therefore unknown. Dr. Wolf has addressed the unknown number of reported OR fires but not the occurrence of flash fire or near misses. We can review H. W. Heinrich’s pyramid theory of accident severity, which addresses the concept of near-miss data. The pyramid theory of accident severity is typically depicted as follows:
In Heinrich’s 1931 study of accident severity found that for every single serious injury that occurred, one could expect that there were 29 minor injury accidents and 300 near-miss no injury incidents within that same statistical sampling of accidents. Although a one-to-one comparison of accident near-misses and OR fire near-misses is not quantifiable at this time, we can speculate that a similar relationship exists between serious OR fires and OR fire near-misses. Approximately 40 years later, the Insurance Company of North America conducted a more comprehensive study of injury accidents. This study involved the review of 1.7 million injury accidents and the ratios in the classifications were about the same as the Heinrich study. The Insurance Company of North America’s accident pyramid of accident severity typically depicted as follows:
