Presentation and physician action

A 29-year-old woman came to a surgical center for removal of an infected epidermoid cyst on her neck.

The patient was taken to the operating room (OR), where an anesthesiologist started her on oxygen, four liters per-minute by nasal cannula. During surgery, Plastic Surgeon A used an electrocautery device on a bleeding vessel. This caused a flash fire under the surgical drapes, which were positioned around the patient’s neck and face. 

The fire was immediately extinguished with hand pressure and by pouring saline on it.  The procedure was stopped, and the patient was awakened for a full examination. 

The patient had burns on her forehead, nose, cheeks, and lips. She was transferred to a nearby medical center burn unit. She underwent skin grafting but had residual scarring from the burns. 

Allegations

The patient filed a lawsuit against the anesthesiologist, alleging failure to ensure the area around the surgical drapes was free of oxygen before the surgeon used a cautery device. Plastic Surgeon A and the manufacturer of the electrocautery device were also sued.

Legal implications

The plaintiff’s experts claimed that the anesthesiologist and the plastic surgeon breached the standard of care by failing to:

• stop the patient’s oxygen with sufficient time before using the cauterizing tool;
• arrange the drapes so oxygen could drain away from the operative site;
• properly apply an incise drape to isolate the patient’s head and neck; and
• use a lower oxygen level before using the cauterizing tool.  

Defense consultants had mixed opinions about the defendants’ actions. One consultant stated that fires are a well-known complication of surgery when using electrocautery devices around a patient’s head and neck area, as oxygen can pool under the drapes allowing a fire to start in the oxygen-rich area.

This consultant stated that the anesthesiologist and the plastic surgeon overlooked the risks and did not follow common precautions for using electrocautery in a heavily oxygenated environment.

Another consultant stated that this was an inadvertent incident that occurred despite the good care and intentions of the anesthesiologist, plastic surgeon, and OR staff. The anesthesiologist documented that he stopped oxygen before the plastic surgeon began using electrocautery.  However, he did not document how much time passed between when he stopped the flow of oxygen and when the surgeon began to cauterize the blood vessel.

Disposition

This case was settled on behalf of the anesthesiologist, the plastic surgeon, and the manufacturer of the electrocautery device.

Risk management considerations

According to the Food and Drug Administration, approximately 600 surgical fires occur in the United States annually. While this number may be small compared to the large number of surgeries performed each year, a surgical fire can have severe consequences for patients, including serious injury, disfigurement, or death.¹

The Joint Commission specifically points to “using electrosurgical devices in ENT surgery with the patient under mask or nasal cannula oxygen administration” as a potential contributing factor to surgical fires. The commission also states that 70 percent of surgical fires are caused by using electrosurgical devices. ²

Risk of fire in the OR can be lessened by creating greater awareness among surgical staff about ignition sources (electrosurgical devices, defibrillators, lasers, and fiber optic light cords) and fuel sources (drapes, towels, sponges, gauze, alcohol-based wipes, and the patient’s body hair.) Oxidizer sources include oxygen, nitrous oxide, and anesthesia machines/ventilators. It is important for all surgical staff members to strictly adhere to the recommended uses, care, and/or disposal of all materials and equipment in the OR.

Establishing written policies and procedures that directly address fire safety in the OR may help lessen the risk of surgical fires. Consider adding the following measures to your safety protocols.

• Include a fire risk assessment in the surgical time out. Along with reviewing the patient’s identity, procedure, and surgical site, add a review of any potential ignition sources, fuel, and oxidizers in the surgical environment and where they are located in relation to the surgical site on the patient. This will heighten awareness of any risks and put staff on high alert around these materials and conditions. Also review the location of fire extinguishers and saline in the OR.
• Encourage all members of the surgical team to continuously assess potential fire hazards during surgery and to immediately speak up if they identify any risk of a possible fire.
• Conduct staff training on fire prevention in the OR. Assign specific roles and responsibilities to each member of the surgical team to perform in the event of a fire. Include fire drills and emergency evacuations of staff and of the patient. Identify an evacuation location for the patient who may need emergency care or whose surgery cannot be stopped for an extended period.
• If working in a hospital or surgical center, report any surgical fire to your facility’s incident reporting system. These reports help identify potential areas of improvement that can further reduce fire risk. ²

Sources

1. FDA: Recommendations to Reduce Surgical Fires and Related Patient Injury. OR Today. May 30, 2018. Available at https://ortoday.com/fda-recommendations-to-reduce-surgical-fires-and-related-patient-injury/. Accessed May 1, 2023.
2. Updated surgical fire prevention for the 21^st century. Sentinal Event Alert. Issue 68, October 18, 2023. The Joint Commission. Available at https://www.jointcommission.org/-/media/tjc/newsletters/sea-68-surgical-fire-prevention2-10-9-23-final.pdf. Accessed May 1, 2023.

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