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Summary

In January 2017, I read an article in Outpatient Surgery involving an elderly patient in the US who suffered multiple burns following the use of chlorohexidine bottled alcoholic prep. The Oregon woman filed a million-dollar lawsuit against the Oregon Outpatient Surgery Center in Tigard, Ore., saying she suffered severe burns when her face caught on fire during an electrocautery procedure.

Having read this tragic story and escalated it to my theatre manager and colleagues, I decided to design and evaluate a FRAS (Fire Risk Assessment Score) and use it as part of the WHO Surgical Checklist at "time out" to raise awareness of fires in operating theatres.

Content

Here is the FRAS tool I implemented:

Fire risk assessment tool.pdf

Other useful resources I found:

Scoring_Fire_Risk-2.pdf Surgical Site Fire Triangle.pdf Surgical_Fire_Poster (1).pdf

Video:

Fire hazard demo by Zaamin Hussain and Mike Reed

Demonstration:

"Burning Bruce" drives home the reality of surgical fires - article in Outpatient Surgery

 

 

User Feedback

Recommended Comments

wow! I remember this being an issue that we discovered in the data being reported to the NRLS soon after we launched it in 2003. I had thought that we had issued a patient safety alert on it soon afterwards. It is sad to see that 15 years later, these incidents are still happening

@Clive Flashman I so agree. I also remember this from NPSA days and am absolutely shocked that reports of theatre fires are still increasing. 

Well done @Kathy Nabbie for sharing your insights, really helpful resources and the disarming video. 

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