**12. Conclusions**

**Figure 2.** Schematic summary of guidelines for optimal approach to operating room fire. Note: Both carbon dioxide and

example, the American Society of Anesthesiologists (ASA) strongly recommends fire safety simulation as a team preparedness tool [12, 89]. It is important that such simulations are as realistic as possible, and that "lessons learned" are discussed during a post-simulation debrief in a constructive, team-oriented fashion, and disseminated afterwards to all stakeholders. Sharing of experiences between different institutions and teams is also very valuable. Helpful information regarding ORF prevention and management is available on the Internet, including the Association of periOperative Registered Nurses (AORN), Anesthesia Patient Safety Foundation (APSF), ASA, and Emergency Care Research Institute (ECRI) websites [105–107]. Finally, in an event of a major unforeseen event in the OR, a crisis checklist has been proposed to help streamline decision-making and team processes required during

"water mist" extinguishers can be utilized. Legend: CO<sup>2</sup> = carbon dioxide; OR = operating room.

**11. The importance of honest disclosure and risk management**

informed decisions about their care can be made [111].

Although uncommon, adverse events and clinical errors do occur, and physicians have an ethical and professional responsibility to honestly disclose such occurrences to patients [109]. Open discussion regarding unfavorable events is an indispensible component of effective clinical risk management in health-care. Failure to do so undermines the public's confidence in the medical profession and has the potential to create legal liability [110]. Moreover, patients need to be informed about medical errors so that additional harm can be avoided, and well-

an orderly response [108].

172 Vignettes in Patient Safety - Volume 3

Although rare, ORFs occur more often than most people realize. Fire safety in the OR is every team member's responsibility, with attention to established safety protocols and focus on prevention constituting the overarching priorities of intraoperative patient care. All stakeholders should be well aware of the "fire triangle" concept, and how the combination of an "ignition source," "fuel source," and "oxygen source" can create a potentially dangerous environment. When ORFs do occur, optimal outcomes depend on immediate recognition, appropriate response, and a coordinated team effort. The focus on team education/training and fire preparedness (through regular exercises and simulations), along with a comprehensive fire safety program, constitute an integral part of preventing adverse occurrences. Patients entrust healthcare provider teams with their lives. With this trust comes the expectation that all team members have excellent knowledge (and control) of risk factors potentially responsible for ORF occurrences. In order to further improve our collective understanding of ORFs, including quantitative risk-factor determination, future efforts should include the development of a national registry that will help facilitate prospective tracking of all ORF occurrences, including their relationship to known risk factors and documented risk-reduction strategies. Only when working together can we effectively achieve the "zero incidence" of major patient safety "never events."
