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Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

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A Look at The Joint Commission

New Sentinel Event Alert Updates Guidance on Preventing Surgical Fires

Lenworth M. Jacobs Jr., MD, MPH, FACS

January 10, 2024

Any surgeon who has experienced a surgical fire knows how horrifying the event can be, and the results can be devastating for patients and their families.

Surgical fires continue to occur, causing significant harm not only to patients, but also to the surgical team and the operating room (OR) environment.

There isn’t a national repository that collects data on surgical fires; ECRI estimates that 90 to 100 surgical fires occur annually in the US.1

In order to help healthcare organizations and surgical teams recommit to surgical fire prevention, The Joint Commission issued a new Sentinel Event Alert, “Updated surgical fire prevention for the 21st century.”

The 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.

Perfect Conditions Exist for Fire in the OR

It is critically important that surgical teams become vigilant in preventing surgical fires in order to keep everyone safe. The operating theater has the perfect conditions for fire: ignition sources, oxygen, and fuel.

  • Ignition sources: Sparks and/or heat from electrosurgical devices cause about 70% of the surgical fires occurring annually in the US.2 One study found that surgical fires were most common with monopolar “Bovie” instruments, causing 88% of fires versus other instruments.3
  • Oxygen or oxidizing agents: An elevated concentration of oxygen and other oxidizing agents that together is greater than the normal atmospheric oxygen level of 21% increases the risk of fire by decreasing the temperature at which fuels ignite.4 Oxygen-enriched atmospheres are reportedly involved in 75% of surgical fires.5
  • Fuel sources: Alcohol-based skin preparations are common fuel sources during surgical fires when not allowed to completely evaporate. Other potential fuel sources include surgical drapes, sponges, towels, gauze, methane in bowel gas, and the patient’s body hair.

From January 1, 2018, to March 29, 2023, 85 sentinel events related to fires or burns during surgery or a procedure were reported to The Joint Commission. Of these fires or burns, 58% were associated with electrosurgical devices, and approximately 15% were related to light sources for electrosurgical devices.

The Joint Commission’s sentinel event database indicates that the leading factors contributing to surgical fires include shortcomings in teamwork and communication, work design, workforce/staff, and equipment. These include:

  • A lack of a shared understanding and communication among surgical team members before or during the procedure
  • An insufficient time-out to assess fire risk or perform a workflow verification step or safeguard
  • A lack of competency to understand or recognize risks
  • Overconfidence and risky behavior as well as distraction or loss of situational awareness
  • Equipment malfunction or failure
  • A lack of training or orientation with the equipment in the OR

Healthcare organizations can significantly lower fire risk to patients, surgical teams, and the OR environment by developing processes and procedures that prevent dangerous interactions between oxygen, ignition sources, and fuel.

The Alert identifies the following evidence-backed actions to prevent fires:

  1. Ensure that the pre-surgery time-out includes a robust fire risk assessment for each surgical and endoscopic procedure
  2. Maintain the local oxygen concentration at less than 30%, whenever possible
  3. Carefully manage electrosurgical devices, light sources and cables, surgical draping, and other risks during a procedure
  4. Provide training to OR staff on how to avoid and manage fires and conduct fire drills
  5. Report all surgical fires via your facility’s incident reporting system
  6. Educate all OR personnel and team members about the risks of surgical fires

The Alert details these safety steps and more.


The thoughts and opinions expressed in this column are solely those of Dr. Jacobs and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

Dr. Lenworth Jacobs is a professor of surgery and professor of traumatology and emergency medicine at the University of Connecticut in Farmington and director of the Trauma Institute at Hartford Hospital, CT. He is Medical Director of the ACS STOP THE BLEED® program.

  1. ECRI. Surgical fire prevention. Available at: https://www.ecri.org/solutions/accident-forensic-investigation-services/surgical-fire-prevention. Accessed September 9, 2023.
  2. The Joint Commission. Making electrosurgery safer. EC News. 2023; 26(5):13-16.
  3. Overbey DM, Townsend NT, Chapman BC, et al. Surgical energy-based device injuries and fatalities reported to the Food and Drug Administration. J Am Coll Surg. 2015;221(1):197-205.
  4. Stormont G, Anand S, Deibert CM. Surgical Fire Safety. In: StatPearls (Internet). Treasure Island, FL: StatPearls Publishing; 2023. Available at: https://www.ncbi.nlm.nih.gov/books/NBK544303.
  5. ECRI. New Clinical Guide to Surgical Fire Prevention. Health Devices. 2009;38(10):317.