Fire Risk Assessment: A Score for Patient Safety

1. Fire Risk Assessment:A Score for Patient Safety Denise Dennison RN BSN CNOR Kenneth L Silverstein MD Judith Townsley RN MSN CPAN KK

2. Objectives Identify factors that contribute to the incidence of fires in the operating room setting. Describe the process for the design and implementation of a Fire Risk Assessment score. Describe the components of a comprehensive educational program that focuses on the prevention of surgical fires. KK

3. Problem Statement How can we as healthcare professionals reduce the incidence of fires in the operating room setting? KK

4. Surgical Fires: An Ongoing Perioperative Challenge �The measure of success is not whether you have a tough problem to deal with, but rather whether it�s the same problem you had last year� John Foster Dulles KK

5. Surgical Fires: An Ongoing Perioperative Challenge The Joint Commission Sentinel Event Alert (June 2003): Preventing Surgical Fires Education of staff Implementing & testing actual response procedures Reporting any surgical fires JJ

6. Surgical Fires: An Ongoing Perioperative Challenge The Joint Commission National Patient Safety Goal 11 (December 2005): Reduce the Risk of Surgical Fires Educate staff on how to control heat sources, manage fuels and establish guidelines to minimize oxygen concentration during surgical procedures JJ

7. Surgical Fires: An Ongoing Perioperative Challenge The Joint Commission FAQs for 2007 National Patient Safety Goals While goal (NPSG #11) is only applicable to the Ambulatory and Office-Based Surgery Accreditation Programs, we still encourage hospitals to implement the recommendations. JJ

8. Consider the Following� If a 4X4 lap pad or drape were to smolder or catch fire, how would you extinguish it? If you used liquid to extinguish it, would it be saline or water? Do you have fire extinguishers in each Operating Room? What kind of fire extinguisher is it? JJ

9. Consider the Following� If you do have a 4X4 smolder/fire and it is extinguished, do you pull the fire alarm or consider the fire out and continue as planned? If you were to evacuate a room due to fire/smoke, how do you mark the room to indicate that everyone is out of the room? Do you require sterile water on every setup? JJ

10. Media Attention U.S. News and World Report 8/10/03 �I�m On Fire� Blazes Sparked in Surgery on the Rise� Seattle Post-Intelligencer Reporter 4/15/05 �State Will Look Into Patient Set on Fire at Virginia Mason?� Surgical Fires: An Ongoing Perioperative Challenge JJ

11. Surgical Fires: An Ongoing Perioperative Challenge Media Attention Health News Digest 8/9/07 �Fires That Occur During Surgery� ABC News 7/26/07 �Group to Issue Surgery Fire Guidelines � Good Morning America 7/20/06 �Could You Catch Fire During Surgery?� JJ

12. Surgical Fires: An Ongoing Perioperative Challenge Media Attention Chicago Sun-Times 8/13/07 �How Could This Have Happened?; Fires in the Operating Room� The Boston Globe 11/7/07 �Fires During Surgeries a Bigger Risk Than Thought� JJ

13. Incidence of OR Fires The true incidence of OR fires is difficult to determine due to the absence of a centralized reporting mechanism ECRI estimates: 50 � 100 OR fires per year 20 per year result in serious injury 1-2 patient deaths annually JJ

14. Location of Surgical Fires