Patient Safety Alert 5: Surgical Fires: Electrosurgical Cases (PDF)

The AMC PSO has identified a series of practices employed to address the factors that can contribute to surgical fires.

Safety Strategies: Prevention

  • Interventions should be directed at the entire team rather than the provider wielding the electrosurgical unit (ESU).
  • Each member of the team must be constantly aware of changing risks during the case (e.g., patient shifting causing tenting that creates an oxygen rich environment) and be empowered to identify and address these risks.
OR Fires
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Team strategies to prevent electrosurgical fires.


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Publications such as whitepapers and guidelines derived from the AMC PSO convenings.

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