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    Summary

    Surgical fires are a serious a patient safety issue. In this blog, Patient Safety Learning analyses a recent response from Maria Caulfield MP, Minister for Patient Safety and Primary Care, to several questions tabled in the House of Commons about surgical fires in the NHS, and outlines the need for further action to prevent these incidents.

    Content

    The prevention of surgical fires (one that occurs in, on, or around a patient undergoing a surgical procedure) is an internationally recognised patient safety issue. Although rare, these incidents can cause serious harm to both patients and healthcare professionals and, in some cases, result in life-changing injuries.

    How frequently do surgical fires occur in the NHS? The Short Life Working Group for the prevention of surgical fires looked at this issue in their report published last year, A case for the prevention and management of surgical fires in the UK.[1] They found that:

    • from Freedom of Information requests, in the 2010-2018 period there were a total of 96 recorded surgical fire incidents declared by NHS England Acute Trusts and Welsh Health Boards.
    • a search of National Reporting and Learning System (NRLS) between January 2012 and December 2018 identified 37 reports of surgical fires.

    Noting the discrepancies in these figures, they suggested that there “are issues to be addressed concerning clear and effective reporting of incidents, and a need to work on a standardised approach”.[2]

    The Working Group suggested in their report that surgical fires should be classed as a Never Event, a serious incident that is entirely preventable. The Association for Perioperative Practice (AfPP) have also called for this, stating:

    “It is vital that we put effective protocols in place and ensure that preventable surgical fires are classified as a Never Event, to send a message to the NHS that a patient’s safety while undergoing surgery is indeed a priority, and to bring the NHS in line with other international healthcare systems approaches.”[3]

    Questions in the House of Commons

    Jim Shannon, Member of Parliament (MP) for Strangford, recently tabled five written questions in the House of Commons on the issue of surgical fires. Written questions allow MPs to ask for information on the work, policy and activities of Government departments, related bodies, and the administration of Parliament.[4]

    Detailed below are the five questions asked by Jim Shannon MP:

    1. To ask the Secretary of State for Health and Social Care, how many surgical fires occurred in operating theatres in NHS England Trusts from April 2019 to October 2021.[5]
    2. To ask the Secretary of State for Health and Social Care, pursuant to the Answer of 24 November 2020 to Question 114184, what steps the national patient safety team at NHS England and NHS Improvement have taken to adopt the recommendations and guidance of the Expert Working Group on the prevention of surgical fires.[6]
    3. To ask the Secretary of State for Health and Social Care, with reference to the Answer of 24 November 2020 to Question 114184 on Operating Theatres: Fire Prevention, whether (a) his Department and (b) the Centre for Perioperative Care have taken steps to implement the recommendations and guidance of the Expert Working Group on the prevention of surgical fires.[7]
    4. To ask the Secretary of State for Health and Social Care, whether his Department has plans to revise the NHS Never Events policy and framework to classify surgical fires in operating theatres as a Never Event.[8]
    5. To ask the Secretary of State for Health and Social Care, if he will instruct NHS Improvement to require the Centre for Perioperative Care to consider preventative guidelines on surgical fires as part of the National Safety Standards for Invasive Procedures Redevelopment workstream.[9]

    Maria Caulfield MP, Minister for Patient Safety and Primary Care, responded to each of these five questions with the following statement:

    “NHS England and NHS Improvement do not hold information on the number of surgical fires. The National Reporting and Learning System does not have a category to provide data on the number of surgical fires reported.

    NHS England and NHS Improvement continue to support the Expert Working Group and other stakeholders in development of guidance on the prevention of surgical fires in operating theatres, ensuring the Expert Working Groups recommendations are adopted and implemented across the National Health Service. The Centre for Perioperative Care (CPOC) is a cross-specialty collaboration dedicated to the development of perioperative care of patients and are best placed to consider and incorporate the work of the Expert Working Group into their wider National Standards for Safety in Invasive Procedures. The NHS National Patient Safety Team will continue support the CPOC’s consideration of the work of the Expert Working Group.

    There are no plans to revise the NHS Never Events policy and framework to classify surgical fires in operating theatres as a Never Event. Such events are defined as serious incidents that are wholly preventable because national guidance or safety recommendations that provide strong systematic protective barriers are available and should be implemented by all providers. As there is currently no national guidance or safety recommendations to prevent surgical fires in operating theatres, these incidents cannot be defined as a Never Event.

    NHS England and NHS Improvement will review any new guidance on the prevention of surgical fires in operating theatres when it is published.”

    Reflections on the Government’s response

    Considering the Minister’s response to these questions, we have identified two specific areas of concern:

    1. Implementing and assessing progress

    Although surgical fires are not common, they are clearly serious patient safety incidents and should be preventable. It is, therefore, concerning that NHS England and NHS Improvement do not hold any information on the frequency of these events. It is vital that we understand when these incidents are happening and fully examine their causes, if we are to successfully implement changes that prevent their future occurrence.

    The Minister states that NHS England and NHS Improvement are working to ensure that the Working Group’s recommendations on surgical fire safety are implemented across the NHS. We think it would be helpful if the NHS publishes an update on its progress, so we can better understand the urgency of the action being taken on this matter.

    This update from NHS England and NHS Improvement should provide clarity on:

    • how the frequency and occurrence of surgical fires is being monitored.
    • how the implementation of the Working Group’s recommendations will be monitored.
    • once implemented, how the effectiveness of these recommendations will be evaluated.

    Without data on the frequency of surgical fires and clear oversight and monitoring of this, how can we assess whether patient safety is being improved?

    2. Should surgical fires be classed as Never Events?

    In her response, the Minister states that surgical fires in operating theatres do not meet the current criteria to be classed as a Never Event as there are not the existing guidance or safety recommendations in place to define these as “wholly preventable” incidents.

    However, as her response also states that guidance and recommendations from the Working Group are now being implemented, we would ask NHS England and NHS Improvement to consider whether this could form the basis for the criteria needed to class this as a Never Event.

    Commenting on this, Lindsay Keeley, Patient Safety and Quality Lead at the AfPP, said:

    “Classifying surgical fires as a Never Event could help address many of the weaknesses in the system that stand in the way of improvement and patient safety. Current guidance and safety recommendations do exist regarding risk management around fire safety in the perioperative environment AfPP (2016). However, having worked in this environment for over thirty years, the significant risk of surgical fires, and physical patient injury, clearly exists. The cost to the NHS should be a primary concern, from 1 April 2009 to 31 March 2019, NHS Resolution were notified of 631 clinical negligence claims relating to surgical burns to patients. Out of these 631 claims, 459 were settled, 58 were unmeritorious and 114 are still open. This has led to NHS Resolution paying £13.9m in damages and legal costs on behalf of NHS organisations.

    It is in the best interest of the NHS to mitigate against the risk of surgical fires occurring in operating theatres by providing mandatory surgical fire training and guidance. Surgical fires should never happen, the rationale to classifying surgical fires as a Never Event is to prevent these from ever happening. Investigating why these occur through root cause analysis will examine issues of compliance, and the robustness of local processes and procedures. AfPP will continue to raise awareness of the risk of surgical fires, whilst determining standards and best practice in reducing patient harm.”

    Patient safety actions needed

    To address the concerns we have highlighted in this blog, Patient Safety Learning believes that NHS England and NHS Improvement should take the following actions regarding surgical fires in operating theatres:

    1. Publish a progress update on its work to implement the Expert Working Group’s recommendations on the prevention of surgical fires. This should include details of how the frequency of these incidents is being monitored and how the effectiveness of implementation of the recommendations will be evaluated.
    2. Formally review the potential for surgical fires to be classified as Never Events.

    Related reading

    Kathy Nabbie, Development of the Fire Risk Assessment Score (FRAS) in theatres, 26 October 2020
    Kathy Nabbie, How I raised awareness of fires in the operating theatre, 15 October 2019
    The Surgical Fires Expert Working Group, A case for the prevention and management of surgical fires in the UK, September 2020

    References

    1. The Surgical Fires Expert Working Group, A case for the prevention and management of surgical fires in the UK, September 2020
    2. NHS England and NHS Improvement, Never Events policy and framework, Revised January 2018
    3. Association for Perioperative Practice, Surgical Fires Must Become ‘Never Events’, 10 August 2020
    4. UK Parliament, Written questions, answers and statements, Last Accessed 19 November 2021
    5. UK Parliament, Operating Theatres: Fire Prevention – Question for the Department of Health and Social Care, UIN 73827,12 November 2021
    6. UK Parliament, Operating Theatres: Fire Prevention – Question for the Department of Health and Social Care, UIN 73828, 12 November 2021
    7. UK Parliament, Operating Theatres: Fire Prevention – Question for the Department of Health and Social Care, UIN 73829, 12 November 2021
    8. UK Parliament, Operating Theatres: Fire Prevention – Question for the Department of Health and Social Care, UIN 73830, 12 November 2021
    9. UK Parliament, Operating Theatres: Fire Prevention – Question for the Department of Health and Social Care, UIN 73831, 12 November 2021

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    A really good article. I personally will be taking this to my next safer surgery meeting at the organisation I work for.

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