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  • Krishna Ramachandran, MD
  • Yvonne Cheung, MD, MPH


For most people, a fire in an operating room during surgery is unimaginable. Professionals in OR settings know about the risk, but experts in patient safety want hospitals and providers to focus more on lowering the potential for fire during surgery.

“Every year across the U.S., there’s, there are hundreds of patients that are harmed by fires in the operating room or the procedural suites.”

Dr. Krishna Ramachandran is Associate Professor of Anesthesiology at Harvard Medical School and Vice Chair of Quality, Safety and Innovation at Beth Israel Deaconess Medical Center in Boston.

“This is despite several practice guidelines by established patient safety organizations and also Joint Commission standards that imbed risk assessments and action into standard work. So, we were interested in answering the question, ‘Why do fires continue to occur in the operating room?’”

Through the Academic Medical Center Patient Safety Organization, AMC PSO, Dr. Ramachandran and other experts examined what is behind the problem. The AMC PSO is a component entity of CRICO. The PSO convened a Task Force of subject matter experts in nursing, anesthesiology, surgery, and patient safety to consider the question of why fires continue to occur in operating rooms, and what to do about it.

Early in 2022, the PSO’s OR Fire Safety Guidance Document Task Force issued a set of recommendations to improve prevention and reduce harm.

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“We discovered that there was variation in the implementation of standardized guidance to identify and mitigate risk in terms of preventing OR fires.”

Dr. Yvonne Cheung is an anesthesiologist and the Director of Quality for Mt. Auburn Hospital in Cambridge, Massachusetts. Dr. Cheung was also a member of the Task Force. She describes a hypothetical example of how a fire might occur if there were insufficient time for alcohol to evaporate before starting the procedure.

“Either someone forgets to watch the timer, set the timer or the clock and so you don’t wait the necessary three minutes for the alcohol to fully evaporate. Drapes are up, they’re paper. The Bovie or the cautery is set. The procedure starts and the first spark that comes from the electrocautery ignites because the alcohol is the fuel. Oxygen is the accelerant, and you got the spark that ignited and that’s your fire.

One of the first things the AMC PSO guidance document zeroes in on is process variability.

“Any time there’s variation in how a process is carried out for whatever reason, that introduces a risk that then there’ll be an alternate pathway or a different direction that does not yield the desired outcome.”

The task force reviewed the literature and existing guidance, as well as some baseline information about current approaches to fire assessment. What emerged were five discrete areas of variability. These include: how individual institutions stratify OR fire risk, time their risk assessments, identify responsible leaders, ensure accountability, and close knowledge gaps. The group developed recommendations for reducing risk in each of these five areas of vulnerability. One might be more important than the rest, in Dr. Ramachandran’s view.

“One for me is really standardizing risk assessment and attaching clear actions. Because without these two things, the whole activity is somewhat meaningless. Teams have to embrace a culture of disciplined execution, both the risk assessment and ensuring that the preparedness measures are in place.”

Dr. Ramachandran says a second vital improvement measure is to simplify the stratification of OR fire risk. Some institutions may use several risk levels as they assess the potential for fire. The task force encourages a simpler scheme—possibly just two levels: elevated and standard risk. For Dr. Cheung those elements can be worked out by each institution, but accountability is an important factor to make things safer:

“I mean that’s something that an organization can develop and say it’s whether it’s two, three or four risk levels or the knowledge deficits can certainly be educated and training can be given for. But if no one owns the responsibility consistently, I think then it becomes very difficult to have anyone own the responsibility, and the risk there is that it doesn’t get done. And not so much because you can put it into the checklist, but someone really needs to take ownership and then have the team also say, well, this is what I can do. Each team member individually says this is what I can do to mitigate the risk. You know, the circulator can make sure that they own the responsibility for making sure that three minutes have elapsed before anyone starts, you know, the procedure so that the alcohol prep has enough time to dry. The anesthetist can own the responsibility of using the least amount of oxygen needed to maintain the patient’s oxygen saturation. But without someone owning the overall…, it’s hard to really then define individual team owners for each part of that responsibility.”

The “Patient Safety Guidance for Perioperative Fire Safety” recommendations document is available upon request at CRICO’s web site, www.rmf.harvard.edu/ORfireprevention

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