Patient having total knee procedure.Implantable hardware being put in using cement.The anesthesiologist noted fire on the floor beside of the pa.A piece of cement was on fire with visible flames.The circulating nurse got a bottle of water and poured over the patient drapes and on the floor.It was then realized that the pa's surgical gown had a large hole in front of her surgical gown.Patient drapes had large holes burned and multiple small holes.Patient was checked for injuries, none observed.The pa was using the electrosurgical pencil to scrape the cement; accidentally hit the cauterize button, which ignited the cement, which then fell onto the drapes and went unnoticed.O.R unit director and charge nurse were immediately notified.At ending surgeon was scrubbed at the time of incident and aware of the situation.Patient was uninjured and went to pacu.No staff injuries occurred.This event underwent a root cause analysis meeting about two weeks after event.During rca meeting, the ortho attending surgeon and pa discussed that the bone cement had a much stronger odor on this data.The surgeon has not been impressed with the overall quality of the bone cement product for the past two years.
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