July 14, 2014, Crain’s reported that “a series of operating
room fires” burned patients at the Cleveland Clinic in 2009 and
2010. Staff members were forced to undergo extensive training on how to
prevent such incidents in the future, but hospitals in general are reluctant
to change their procedures unless something happens in their own OR.
In June 2013, a patient at another facility suffered second-degree burns
to his neck and shoulders during an emergency tracheostomy. The surgical
team violated the FDA’s Preventing Surgical Fires Initiative by
using an alcohol-based cleanser to prep the patient’s skin, administering
100 percent oxygen, and turning on the cauterizing tool without waiting
three minutes for the alcohol prep to dry.
“All of a sudden, there was fire,” the anesthetist told investigators.
The hospital’s CEO told Crain’s that the surgical team “responded
to the incident appropriately” and the facility has banned alcohol-based
solutions in most of its emergency procedures. The company that makes
the sanitizer that was used during that operation also warned doctors
not to use its product near electrosurgical tools and, last November,
changed its product label to that effect.
Alcohol-based antiseptics are causing an increasing number of fires, and,
in 2010, Cleveland Clinic told reporters that it had removed these solutions
from all of its operating rooms. But most fires “involve the ignition
of concentrated oxygen by electrosurgical tools used in upper-body procedures,
where patients receive the highly flammable gas through face masks and
nasal devices,” said Crain’s. “Studies of
anesthesia malpractice claims suggest there has been a rise in incidents.”
Between 2004 and 2011, about 240 fires occurred per year in operating rooms,
according to forensic investigator ECRI.
The FDA recommends that patients recognize the risk and ask whether their
surgical team is familiar with dangers — such as facial hair and
draping — and the location of fire extinguishers.