Surgical fires and burns: The untold stories and efforts for prevention

Summary

Imagine waking up after surgery and not only dealing with the pain and stress of the procedure itself but also with the added trauma of severe burns. This nightmare scenario is a reality for some patients who have caught fire undergoing surgical procedures within the perioperative environment. 

The Surgical Burns Action Group* is working to change this. Chair Lindsay Keeley shares with the hub the Group's mission and key initiatives.

Content

The reality of surgical fires

Surgical fires occur when flammable materials like surgical drapes or alcohol-based skin prepping agents come into contact with an ignition source, in the presence of an oxidiser such as oxygen. This dangerous mix can lead to a fire right on the operating table.

These fires pose significant risks, not just to the patients who are directly affected but also to the healthcare professionals involved. The consequences range from minor injuries to severe burns, respiratory complications and, in extreme cases, death. The severity of these burns can vary, from superficial burns to deep tissue damage, depending on the exposure and the extent of the fire.

The human stories behind the statistics

From 1 April 2009 to 31 March 2019, NHS Resolution was notified of 631 clinical negligence claims related to surgical burns. Out of these, 459 were settled, 58 required no further review and 114 remained open. The damages and legal costs associated with these cases amounted to £13.9 million.[1] 

But beyond these numbers are real people with real stories. Personal accounts of patients harmed by surgical fires reveal the profound and lasting impact of these events. Patients often suffer from:

• Localised burns and subsequent infections.
• Inhalation injuries leading to chronic respiratory problems.
• Difficulty breathing due to scar tissue build up.
• Pain from repeated surgeries.
• Emotional trauma and long-lasting psychological scars.

Preventing the preventable

The good news is that surgical fires are entirely preventable. Implementing strict safety protocols and adhering to established guidelines can make a significant difference.

Key measures include proper handling and use of flammable materials, minimising oxygen concentration in the surgical field and taking precautions to prevent ignition sources, such as using safer methods of skin preparation.

Despite these straightforward measures, there is still a lack of national guidelines in England or sufficient risk training, leading to inconsistent prevention and reporting practices. In contrast, the United States has made surgical fire prevention a priority, with the FDA issuing national guidance in 2018.[1]

The need for change: the Surgical Burns Action Group’s mission

The failure to adequately address surgical fires often stems from a lack of awareness about the problem's scale. This unawareness is partly due to the ambiguous mandatory reporting structures and bodies, as well as a lack of transparency in the data of reporting surgical fires or burns. The lack of transparent data and ambiguous reporting pathway means healthcare professionals may not consistently report these incidents, leading to underestimation and inadequate policy response.

The Surgical Burns Action Group is working to change this. Our mission includes several key initiatives:

• Mandating reporting: Advocating for the mandatory reporting of surgical fires and burns across NHS England and its constituent bodies and providers.
• Improving patient information: Ensuring patients are well-informed about the potential risks of surgical fires and their care options.
• Enhancing training and education: Providing comprehensive training for healthcare professionals on the safety requirements to prevent surgical fires, including proper skin preparation.

By implementing these recommendations, Surgical Burns Action Group aims to enhance patient safety and reduce the occurrence of surgical fires and burns, fostering a safer healthcare environment for all.

Reference

1. A case for the prevention and management of surgical fires in the UK. Expert working group recommendations. September 2020.

Related resources on the hub:

• Surgical fires poster: raising awareness, avoiding preventable harm
• NHS Resolution: Did you know? Preventing surgical burn
• Fire safety in the operating room
• Preventing surgical fires: What action is being taken?
• Development of the Fire Risk Assessment Score (FRAS) in theatres
• How I raised awareness of fires in the operating theatre

About the Author

Lindsay Keeley is Chair of the Surgical Burns Action Group and Patient Safety & Quality Lead at the Association for Perioperative Practice (AfPP).

*Support for the Surgical Burns Action Group is provided by Becton Dickinson who fund the secretariat, delivered by PLMR Healthcomms. Members of the Surgical Burns Action Group receive no payment for their involvement in the group.