**10. Checklists, communication, education, safety protocols, and teamwork**

It has been noted that in the presence of all three components necessary for intraoperative fire ignition, the risk of ORF may be further elevated by poor team communication and coordination [90]. From patient safety perspective, virtually all surgical fires should be preventable. Standardized OR safety checklist aimed at reducing the risk of ORF, either alone or in combination with other existing checklists, has been proposed as one potential solution to the problem [91–93]. Another area where iatrogenic fires can occur, yet the issue appears to be relatively neglected despite some procedural similarities to the OR, is the clinical setting of the emergency department [94].

In case of cutaneous burn, skin is an effective thermal barrier, causing most of the immediate damage to be confined to epidermis and dermis. At the same time, various humoral mediators (cytokines, prostaglandins, oxygen free radicals, histamine, complement) are released that may result in vasoactive response, increased capillary permeability, and the appearance of local as well as distal tissue edema. Beyond the general pathophysiology of the burn wound, additional factors contributing to the overall physiologic response include resuscitation fluid administration, effects of various therapeutic agents, impaired host defense leading to elevated risk of infection, endocrine system changes, and the associated hypermetabolic state that affects metabolism

If airway or intracavitary fire is present, the abovementioned considerations may become amplified, potentially worsening the clinical prognosis [35, 74, 75]. Injuries involving the airway may become life threatening if not promptly and properly managed [48]. More specifically, what may appear to be a minor injury can result in severe tissue edema that severely restricts or obstructs an airway over the course of a few hours [74, 76, 77]. Long-term follow-

Additional consequences of ORFs, above and beyond direct patient harm, include serious medico-legal repercussions, financial costs, and severe reputational damage to both involved providers and their institutions [79, 80]. Moreover, such events inculcate mistrust toward the healthcare system among the public [80]. Although the majority of patients who sustain medical injury do not file lawsuits, the medical system is riddled with an abundance of frivolous claims, the cost of which is not trivial [81–84]. It has also been noted that lack of provider awareness, combined with inadequate levels of communication, may result in elevated malpractice risk [85]. The development of appropriate internal reporting mechanisms and educational programs may help mitigate the overall legal risk associated with adverse events, including ORFs [85, 86]. Factors known to prevent litigation by patients who suffered complications include excellent surgeon-patient relationship, full and honest disclosure, and effec-

Consequences of unusual or elevated incidence of ORFs can be significant, up to and including mandatory closure of operative suites at an institution [2]. Consequently, thorough assessment of risks, institutional protocols, and employee competency in this critical area is mandatory [2]. Regular (e.g., quarterly) fire drills may help reinforce the knowledge of essential patient safety protocols and serve to refresh key information among the OR staff [89].

It has been noted that in the presence of all three components necessary for intraoperative fire ignition, the risk of ORF may be further elevated by poor team communication and coordination [90]. From patient safety perspective, virtually all surgical fires should be preventable. Standardized

**10. Checklists, communication, education, safety protocols, and**

across a broad range of tissues (e.g., muscle, liver, kidneys, gastrointestinal tract) [73].

**9. Medico-legal, reputational, and regulatory implications of ORF**

tive communication between patients, providers, and teams [87, 88].

**teamwork**

up is required in cases of severe airway injury [78].

170 Vignettes in Patient Safety - Volume 3

One important focus of existing guidelines (with some exceptions) is that the traditional practice of using highly concentrated oxygen should be discontinued during head, face, neck, and upper chest surgery [28, 46]. The recommended practice is to use medical air whenever possible in such cases, and if the patient's condition warrants supplemental oxygen, additional precautions should be taken to protect the surgical field from oxygen "contamination" [2]. The exception to this rule would be a case in which a patient must remain responsive but requires supplemental oxygen while undergoing a procedure involving the head, face, neck, or upper chest. Under such circumstances, the lowest concentration of oxygen should be employed (e.g., 30%), and if concentrations exceed 30% prior to using any surgical energy source, one should stop oxygen and deliver medical air at 5–10 L/min for at least 1 min to dissipate any trapped oxygen [95, 96]. As previously outlined, tracheal incision should only be performed using "cold" devices such as scalpels or scissors. Finally, communication among the team members is essential, including universal patient safety education and utilization of patient safety checklists [97].

Because ORF requires the simultaneous presence of an oxidizer, an ignition source, and a fuel, the key to prevention is intentionally minimizing (or eliminating, if applicable) one or more of these components so combustion is not possible [98]. Thus, the overall framework for ORF prevention must incorporate specific steps to identify risk level for each surgical case, ensure proper use of surgical energy devices, safe and appropriate use of supplemental oxygen, excellent communication and coordination, as well as meticulous attention to detail when using any potentially flammable materials to prep and/or drape the surgical field [99]. The assessment of fire risk potential should take place during the universal surgical time-out for every single patient and for each individual procedure [99, 100]. The fire risk is calculated/ estimated by considering all possible risk factors associated with a particular surgical procedure [101, 102]. The resulting "risk score" (with "1" representing "low risk," "2" representing "intermediate risk," and "3" representing "high risk") should then be communicated to the surgical team during the "time out" or "pre-op briefing" [102].

In the OR, each healthcare worker takes the "ownership" of a part of the fire triangle. For example, alcohol-based skin preparations have become more common as a source of fuel since the Centers for Disease Control and Prevention identified them as the preferred skin disinfection method. Thus, the team member who applies the prep (e.g., circulating nurse) must work closely with the surgeon who controls the surgical energy device, and these stakeholders must ensure that the potentially flammable prep agent is completely dry, without any identifiable pooling, before proceeding with the use of electrocautery [99].

One never knows who will be present when the fire occurs; thus, the role of each team member may change in any given scenario. A simplified guideline for all three broad types of ORF (e.g., involvement of airway, cutaneous/non-airway, and environment) is presented in **Figure 2**. High degree of flexibility on the part of all team members is required, and this can only be accomplished in the presence of meticulous preparation, optimized use of resources, readiness drills, simulation, and other forms of team practice [103, 104]. For

Honest disclosure can be challenging for practitioners as it may be difficult to recognize errors openly before both patients and colleagues [112, 113]. In addition, physicians' fear of litigation can also pose as a major barrier to frank disclosure [114]. However, when handled appropriately, immediate and genuine disclosure of errors frequently leads to improved patient rapport and fewer malpractice claims [115, 116]. Practitioners are encouraged to follow hospital-specific guidelines for the disclosure of errors, patient safety events, and other risk management issues [117–119]. Disclosure needs to take place in an appropriate setting and at the right time, when the patient and/or their family is/are able to understand and sufficiently process the information provided. The surgeon should always take the lead and approach the patient/family with empathy and concern [120]. Behavior that translates into acts of evasiveness or lack of understanding inculcates mistrust and anger in the patient, which may ultimately lead to a legal action against the physician and/or the hospital [121]. Manner and tone are extremely important aspects of disclosure and often more impactful than the actual content of the discussion. A simple "I am sorry" is often appreciated by the patients and results in a stronger patient-physician relationship. In addition, it is important for the physician to articulate clearly what has been done to overcome consequences of the error and to reassure the patient and their family that every effort

Avoiding Fire in the Operating Suite: An Intersection of Prevention and Common Sense

http://dx.doi.org/10.5772/intechopen.76210

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has been taken to prevent similar events from happening in the future [122].

report them without fearing backlash or facing undue blame [32, 33, 123].

**12. Conclusions**

Open physician-to-patient and physician-to-physician communication is a fundamental aspect of effective clinical risk management and cannot be overemphasized [110]. As outlined throughout the *Vignettes in Patient Safety* book cycle, every health-care organization should encourage the internal development of patient safety champions and strictly enforce policies and procedures that prevent occurrence of adverse events [32]. At the same time, when these incidents do occur, all team members (physicians and non-physicians) should be trained to

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."

**Figure 2.** Schematic summary of guidelines for optimal approach to operating room fire. Note: Both carbon dioxide and "water mist" extinguishers can be utilized. Legend: CO<sup>2</sup> = carbon dioxide; OR = operating room.

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 an orderly response [108].

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

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

Honest disclosure can be challenging for practitioners as it may be difficult to recognize errors openly before both patients and colleagues [112, 113]. In addition, physicians' fear of litigation can also pose as a major barrier to frank disclosure [114]. However, when handled appropriately, immediate and genuine disclosure of errors frequently leads to improved patient rapport and fewer malpractice claims [115, 116]. Practitioners are encouraged to follow hospital-specific guidelines for the disclosure of errors, patient safety events, and other risk management issues [117–119]. Disclosure needs to take place in an appropriate setting and at the right time, when the patient and/or their family is/are able to understand and sufficiently process the information provided. The surgeon should always take the lead and approach the patient/family with empathy and concern [120]. Behavior that translates into acts of evasiveness or lack of understanding inculcates mistrust and anger in the patient, which may ultimately lead to a legal action against the physician and/or the hospital [121]. Manner and tone are extremely important aspects of disclosure and often more impactful than the actual content of the discussion. A simple "I am sorry" is often appreciated by the patients and results in a stronger patient-physician relationship. In addition, it is important for the physician to articulate clearly what has been done to overcome consequences of the error and to reassure the patient and their family that every effort has been taken to prevent similar events from happening in the future [122].

Open physician-to-patient and physician-to-physician communication is a fundamental aspect of effective clinical risk management and cannot be overemphasized [110]. As outlined throughout the *Vignettes in Patient Safety* book cycle, every health-care organization should encourage the internal development of patient safety champions and strictly enforce policies and procedures that prevent occurrence of adverse events [32]. At the same time, when these incidents do occur, all team members (physicians and non-physicians) should be trained to report them without fearing backlash or facing undue blame [32, 33, 123].
