Preventing Fires in the Operating Room
FDA Patient Safety News: Show #105, December 2010

An estimated 600 surgical fires occur each year in the U.S. Although most are minor, some result in serious injury, disfigurement, or even death.
The Anesthesia Patient Safety Foundation (APSF) says the vast majority of these fires are preventable. With the assistance of ECRI Institute, APSF recently produced a video about why operating room fires occur and the "best practices" to keep them from happening. The video describes the "Surgical Fire Triangle", when an ignition source, a fuel, and oxygen come together.

APSF says that the majority of OR fires occur when high oxygen concentrations are present, particularly in procedures involving the head, neck and upper chest.
An enriched oxygen environment occurs when the concentration of oxygen exceeds that of ordinary room air. APSF says that it is vital for OR personnel to consider whether supplemental oxygen is really necessary for each patient, and describes precautions to take if it is. For example, avoid using an open delivery source such as a nasal cannula.

Ignition sources, like electrosurgical pencils and lasers, form another leg of the "Surgical Fire Triangle". Fuel sources, such as drapes and alcohol-based prep solutions, complete the triangle.

To help OR team members learn how to prevent operating room fires, APSF is distributing complementary copies of the video on DVD. Request the DVD or watch it online at:

Additional Information:

Anesthesia Patient Safety Foundation. Video - Prevention and Management of Operating Room Fires. OR Fires video:

FDA Patient Safety News is available at