Fire Safety

CSPS Update on Preventing Surgical Fires - Collaborating to Reduce Preventable Harm

Roy H. Constantine  PA-C, MPH, PhD, FCCM, DFAAPA

Daniel Vetrosky, PhD, PA-C, DFAAPA

Former CSPS Representatives and Chair

Article originally printed in Sutureline: Sep/Oct 2015 p. 15


Surgical fires are fires that occur in, on or around a patient who is undergoing a medical or surgical procedure. An estimated 550 to 650 surgical fires occur in the United States per year, some causing serious injury, disfigurement, and even death.1


The FDA introduced initial launch activities for the prevention of surgical fires in October of 2011. The impetuses for this initiative were that “surgical fires” are preventable medical errors. The FDA formed collaborative stakeholder relationships to overcome barriers that may exist and to incorporate interventions to minimize surgical fires. For the past several years the Food and Drug Administration campaigned and supported a “Preventing Surgical Fires Initiative.”  The FDA working along with the Joint Commission (TJC) reached out to the Council on Surgical and Perioperative Safety to continue to support this important initiative. In June of 2015 the transferring of the Preventing Surgical Fire Initiative web pages from the FDA to the CSPS occurred. Nothing has changed; this new venue will continue to promote all the efforts placed in the “Preventing Surgical Fires” initiative to:

  • Increase awareness of factors that contribute to surgical fires

  • Disseminate surgical fire prevention tools

  • Promote the adoption of risk reduction practices throughout the healthcare community

In order to minimize these “Never Events” an “interprofessional learning environment more closely mirrors real-life situations and current health care practice2.”  For example in your operating rooms or procedural areas is a fire risk score performed in a huddle or timeout. In the event of a fire does everyone in the operating room team know what their responsibilities should be?  For instance:

Who will manage the oxygen flow?

Who will handle the endotracheal tube?

Who will douse out the fire on the operating room field?

Who will pull the drapes?

Who will go for the fire extinguishers?


This needs to be done in seconds!!!  Do you believe that your team can accomplish this??

If you haven’t already done so please review the CSPS website at When you click on the “Safe Surgery Resources” link you will find the TJC Collaborative – Prevent Surgical Fires Site. The site contains important information that you can utilize as a patient safety champion.



  1. ECRI Institute New Clinical Guide to Surgical Fire Prevention. Health Devices October 2009
  2. Patterson B. A Model for Simulation-Based Interprofessional Team Learning. PSQH. July/ August 2015