Nigel Roberts examines the evidence around the incidence of surgical fires, as well as current guidance to prevent associated harm. He considers whether surgical fires should be classed as a ‘Never Event’ and whether mitigating steps should be incorporated into the WHO surgical safety checklist
The research on the current three intra-operative ‘Never Events’ has bought to light another potential intra-operative ‘Never Event’ for discussion – surgical fires. ‘Never Events’ are defined as ‘Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers’.1
Early research by Bruley2 concluded that ‘surgical fires are a preventable hazard’, five years prior to the publication of the World Health Organization’s (WHO) surgical safety checklist. So why was the decision made not to class a surgical fire as a ‘Never Event’?
Research suggests that the first recorded surgical fire, occurring on a patient as a result of the use of anaesthetic gases, goes as back as far as 1850 – when ether caught fire during facial surgery.3,4 However, surgical fires remain a significant safety issue today.
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