Alcohol skin preparation causes surgical fires

Abstract

INTRODUCTION: Surgical fires are a rare but serious preventable safety risk in modern hospitals. Data from the US show that up to 650 surgical fires occur each year, with up to 5% causing death or serious harm. This study used the National Reporting and Learning Service (NRLS) database at the National Patient Safety Agency to explore whether spirit-based surgical skin preparation fluid contributes to the cause of surgical fires. METHODS: The NRLS database was interrogated for all incidents of surgical fires reported between 1 March 2004 and 1 March 2011. Each report was scrutinised manually to discover the cause of the fire. RESULTS: Thirteen surgical fires were reported during the study period. Of these, 11 were found to be directly related to spirit-based surgical skin preparation or preparation soaked swabs and drapes. CONCLUSIONS: Despite manufacturer's instructions and warnings, surgical fires continue to occur. Guidance published in the UK and US states that spirit-based skin preparation solutions should continue to be used but sets out some precautions. It may be that fire risk should be included in pre-surgical World Health Organization checklists or in the surgical training curriculum. Surgical staff should be aware of the risk that spirit-based skin preparation fluids pose and should take action to minimise the chance of fire occurring.