Fire in the operating room
An electrocautery device started a flash fire in the operating room.
Fire in the operating room
An electrocautery device started a flash fire in the operating room.
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
According to the Food and Drug Administration, approximately 600 surgical fires occur in the United States annually. 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
In this case, 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.
Sources
- FDA: Recommendations to reduce surgical fires and related patient ipnjury. OR Today. May 30, 2018. Available at https://ortoday.com/fda-recommendations-to-reduce-surgical-fires-and-related-patient-injury/. Accessed October 9, 2026
- The Joint Commission. Sentinel Event Alert 68: Updated surgical fire prevention for the 21st century. JCI News. Issue 68, October 18, 2023. Available at https://www.jointcommission.org/en/knowledge-library/newsletters/sentinel-event-alert/issue-68. Accessed October 9, 2026.
Risk management for anesthesiologists.
Disclaimer
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
According to the Food and Drug Administration, approximately 600 surgical fires occur in the United States annually. 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
In this case, 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.
Sources
- FDA: Recommendations to reduce surgical fires and related patient ipnjury. OR Today. May 30, 2018. Available at https://ortoday.com/fda-recommendations-to-reduce-surgical-fires-and-related-patient-injury/. Accessed October 9, 2026
- The Joint Commission. Sentinel Event Alert 68: Updated surgical fire prevention for the 21st century. JCI News. Issue 68, October 18, 2023. Available at https://www.jointcommission.org/en/knowledge-library/newsletters/sentinel-event-alert/issue-68. Accessed October 9, 2026.
Risk management for anesthesiologists.
Disclaimer
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