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Qual Saf Health Care 2004;13:467-471 doi:10.1136/qshc.2003.005819
  • Error management

Surgical fires: perioperative communication is essential to prevent this rare but devastating complication

  1. M E Bruley
  1. Correspondence to:
 M E Bruley
 Vice President, Accident and Forensic Investigation, ECRI, 5200 Butler Pike, Plymouth Meeting, PA 19462, USA; mbruleyecri.org
  • Accepted 14 August 2004

Abstract

A fire on or within a surgical patient is a continuing risk in modern surgery. Unfortunately, the sensitivity of surgical and anaesthesia staff to this hazard has waned over the past 25 years with cessation of the use of flammable anaesthetic agents. Prevention of surgical fires requires understanding the risks and effective communication between surgical, anaesthesia, and operating nursing staffs. Preventive measures exist but have yet to diffuse sufficiently across professional boundaries. Based on a review of relevant databases, decades of experience from field investigations, and a review of the medical literature, this paper discusses the incidence of surgical fires, the responsibility for prevention in the perioperative setting, and the procedures for surgical fire prevention and extinguishment.

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