Preventing surgical fires in the NHS

A ‘surgical fire’ is a fire that occurs in, on, or around a patient undergoing a surgical procedure. Factors that contribute to the risk of fire in surgical theatres include the use of electrical surgical equipment, lasers and fibre optic lights, that can act as an ignition source, and fuel sources such as surgical fabrics, swabs and alcohol preparation solutions (particularly where these are allowed to pool on or under the patient). The sometimes elevated oxygen concentration in surgical theatres can be a further risk factor.

A fire on or in a patient while in an operating theatre may cause serious injuries to both the patient and healthcare professionals. Patient injuries caused by a surgical fire most commonly occur on the head, face, neck and upper chest, and surgical fires have been recognised internationally a patient safety issue that should be addressed through guidance and training.

In September 2021 the Surgical Fires Expert Working Group published its report, A case for the prevention and management of surgical fires in the UK, which focused on the prevention of surgical fires in the NHS. The Working Group was established in May 2019 from a group of experts from healthcare organisations and bodies across the UK. Their report contains information surrounding the scale of the problem of surgical fires in the UK, in addition to reported experiences of these incidences by both healthcare professionals and patients. It also includes information on prevention, management and training materials. It made a number of recommendations to ensure the prevention of surgical fires in UK hospitals, including that surgical fires be classified as a “Never Event” by NHS England and NHS Improvement.

The NHS in England defines Never Events as “…serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.”

In response to a series of Parliamentary Questions from Jim Shannon, the Department of Health and Social Care Minister Maria Caulfield set out what steps were being taken following the Expert Working Group’s report (see PQ73829, 18 November 2021):

NHS England and NHS Improvement do not hold information on the number of surgical fires. The National Reporting and Learning System does not have a category to provide data on the number of surgical fires reported.

NHS England and NHS Improvement continue to support the Expert Working Group and other stakeholders in development of guidance on the prevention of surgical fires in operating theatres, ensuring the Expert Working Groups recommendations are adopted and implemented across the National Health Service. The Centre for Perioperative Care (CPOC) is a cross-specialty collaboration dedicated to the development of perioperative care of patients and are best placed to consider and incorporate the work of the Expert Working Group into their wider National Standards for Safety in Invasive Procedures. The NHS National Patient Safety Team will continue support the CPOC’s consideration of the work of the Expert Working Group.

There are no plans to revise the NHS Never Events policy and framework to classify surgical fires in operating theatres as a Never Event. Such events are defined as serious incidents that are wholly preventable because national guidance or safety recommendations that provide strong systematic protective barriers are available and should be implemented by all providers. As there is currently no national guidance or safety recommendations to prevent surgical fires in operating theatres, these incidents cannot be defined as a Never Event. NHS England and NHS Improvement will review any new guidance on the prevention of surgical fires in operating theatres when it is published.

• The charity, Patient Safety Learning has published a blog, Preventing surgical fires: What action is being taken? (30 November 2021)
• The Association for Perioperative Practice (AfPP), which aims to enhance skills and knowledge within operating departments and associated areas, has published an article, Surgical Fires Must Become 'Never Events' (10 August 2020)
• Surgical fires: Still a burning issue in England and Wales, Journal of Perioperative Practice (May 2020)
• Operating Room Fires, Anesthesiology (March 2019)