January 30, 2024
In an effort to have healthcare organizations and surgical teams recommit to surgical fire prevention, The Joint Commission (TJC) issued a new Sentinel Event Alert.
According to Lenworth M. Jacobs, MD, MPH, FACS, who writes regularly featured TJC reports in the Bulletin, the new alert “stresses that each member of the surgical team is responsible for assessing all hazards that could contribute to a surgical fire, as well as observing the action of all other team members and speaking up immediately if any preventive risk or evidence of a possible fire is observed.”
The article describes the three “perfect conditions” that can generate a fire in the OR:
Dr. Jacobs notes that the sentinel event database suggests that a lack of teamwork and communication, work design, workforce/staff, and equipment are major contributing factors to surgical fires, and the offers evidence-based actions that hospitals can take to address these gaps.