Try to prevent injury to the patient by having wet towels, fire extinguishers, and saline available to douse the fire.¹⁵

Key preventive steps surgical technologists can take are following the manufacturer’s instructions when using alcohol-based skin prep solutions and alerting the scrub team that the prep solution may not be dry before handing them the first surgical drape. It helps to have a timer in the OR or procedure room because this provides a visible engineering control that mitigates the risk of error. Other steps the surgical technologist can take include making sure the ESU handpiece is always in a holster when not in use. It is the responsibility of the surgical team to make sure the handpiece is properly stored. Paper drapes are flammable, and even drapes that are treated with fire retardant can slowly melt and burn the patient if the ESU handpiece is not in the holster and accidently activated. Another fire prevention step involves fiber-optic light cords, which should

never be turned on unless they are attached to an electrical scope. These cords are an ignition source that can cause drapes to catch fire. “Fiber- optic cables should never be placed on flammable materials and should be turned off when not in use.”44(p263)

The most important factor in preventing surgical fires is education. The surgical team must receive proper training and education to prevent and manage surgical fires; without training and education, we put our patients at risk. Once-a-year fire education may not be enough, because new equipment and technologies are continually being added to the surgical environment. Quarterly fire educational updates should be considered.

JAYNE MacPHERSON

PhD, CST DIRECTOR, SURGICAL TECHNOLOGY PROGRAM BUNKER HILL COMMUNITY COLLEGE

BOSTON, MA

Risk manager’s perspective

Reducing the incidence of serious safety events in their organizations is a core goal for health care risk managers. A risk manager’s first objective is to prevent or reduce the occurrence of patient harm and, second, to reduce exposure to liability losses and other losses. Because of the potential severity of patient injury and subsequent implications after a fire in the OR or procedure room, preventing surgical fires is a top patient safety priority for any risk management program.

High-Reliability Organizations and Enterprise Risk Management

High-reliability principles (eg, preoccupation with failure, reluctance to simplify, sensitivity to oper- ations, commitment to resilience, deference to expertise), when applied in high-risk clinical en- vironments like the OR, can lead to safer practices, fewer errors, and processes that prevent errors that do occur from reaching the patient and causing harm. Enterprise risk management proactively

addresses both risks of loss and opportunities for gain. It is a framework that risk managers can apply across disciplinary linesdindeed, across the health care enterprisedto identify, analyze, and treat risks to patients, operations, employees, and technolo- gies. Application of this framework allows risk managers to keep within legal and regulatory re- quirements while pursuing the financial objectives and the strategic mission of the organization.⁴⁵ There is congruence between the principles of high- reliability organizations and the processes of en- terprise risk management when they are applied with the common goal of protecting the patient and the organization.⁴⁶

Optimizing High-Reliability Organization Principles and Enterprise Risk Management to Prevent Surgical Fires

Health care risk managers rely on collaborative relationships with perioperative nurse leaders, sur- geons, and frontline personnel to proactively

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identify and report adverse events and near misses that create unsafe situations in the surgical setting. Preoccupation with failure means becoming aware of small, seemingly inconsequential errors or de- viances that are symptoms of larger issues. Exam- ples that I have seen during surgical procedures include instances of the ESU handpiece not being holstered when not in use and skin prep solution not being allowed to dry before draping. These practice deviances are indicators of noncompliance and production pressures taking priority over patient protection (ie, patient safety), and deviances like these require leadership intervention to correct. Speaking up and reporting such deviances are the first steps in correcting them to reduce the risk of surgical fires. Doing so requires a culture of safety and a culture of continuous learningdsomething that perioperative nurses and risk managers both work to create but often from different places in the organization.

Being sensitive to operations entails paying atten- tion to what is happening on the front line. Illustrations of this from a risk management perspective include the following:

• Ensure that surgical teams are performing a fire risk assessment before the start of surgical procedures and implementing a plan of care that includes specific fire precautions, such as a formal time out for ear, nose, and throat procedures.
• Provide fire safety training and education for perioperative nurses, anesthesia professionals,

surgeons, and surgical personnel. This includes fire drills and, if possible, simulation for prac- tice and learning.

• Monitor compliance with fire safety policies and assign accountability for behavioral choices and professional practice to perioperative nursing and medical staff leaders.

From a patient safety perspective, the risk of a surgical fire is too great not to prevent. The

occurrence of such an event negatively affects the patient, primarily in terms of human harm, but it also traumatizes the perioperative team mem- bers who are involved. The ripple effects for the health care organization include possible loss of accreditation status, loss of reputation, and a financial downturn.

The adage “everyone is a risk manager” reflects the collaboration among surgical team members and risk managers that is necessary to establish best practices in surgical fire safety that are supported without compromise. This collaboration is exem- plified in a reliability culture of continuous learning, which embraces safety as a core value and embeds it in the enterprise risk management process so that health care organizations can thrive in a changing environment that rewards safe and trusted care.

KATHLEEN SHOSTEK

RN, ARM, BBA, FASHRM, CPHRM SENIOR HEALTHCARE RISK MANAGEMENT

CONSULTANT SEDGWICK

CLIFFORD TOWNSHIP, PA

Patient’s perspective

Not all organizations need to have high reliability. However, those that deal with low-probability, high- consequence events like an OR fire really have no choice.⁴⁷

I am writing from the perspective of the patient or, in my case, as the father of a patient who ex- perienced an airway fire.⁴⁸ His sentinel event oc- curred because of system failures that resulted in a traumatic blowtorch-like fire from his endotracheal

tube into his lungs. After 90 days in intensive care, my son died. I also am writing from the perspective of a chemical engineer and manager who was re- sponsible for running safe hydrocarbon operations for 35 years and for consulting in chemical process safety, culture, and leadership for another 12 years. I am familiar with incidents in a number of industries and have been involved in a few. I have yet to study an incident that was not preventable.

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