AHRQ WebM&M: Morbidity and Mortality Rounds on the Web ► Fire in the Hole!—An OR Fire Commentary by Sonya P. Mehta, MD, MHS, and Karen B. Domino, MD, MPH

AHRQ WebM&M: Morbidity and Mortality Rounds on the Web

Fire in the Hole!—An OR Fire

Commentary by Sonya P. Mehta, MD, MHS, and Karen B. Domino, MD, MPH

A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection for a biopsy-proven adenocarcinoma. After resecting the segment of the colon where the tumor was located, the surgeon realized that he had accidentally lacerated the bladder. The laceration was located and sutured without difficulty, and the decision was made to irrigate the bladder to ensure its wall was intact. As the surgeons went about the task of bowel re-anastomosis (reconnection) in the darkened laparoscopic suite, the nurses set up the bladder irrigation equipment and began to flush the bladder with warm saline. None of the OR staff noticed that in the course of setting up the irrigation equipment, the circulating nurse had hung the large 3-liter bag of irrigating solution from the handle of the anesthesiologists' accessory "slave" monitor, directly above the major transformer that powers the device. As the procedure continued, the bag of saline began to drip directly into the power inverter. Suddenly, sparks and flames began shooting from the monitor tower, and the OR quickly filled with black smoke.

At this hospital, the OR staff conducted daily safety huddles and held timeouts before every procedure, both of which included physical verification and verbalization of fire safety measures available. In this case, the preoperative timeout included all members of the operating team agreeing on the current procedure's fire risk and the nurse verifying and verbalizing the location of the nearest fire extinguisher next to the OR door. The OR team immediately put this training into action. The anesthesiologist quickly shut down the purified oxygen, while the surgical team attempted to halt the procedure before they lost all visualization. The scrub nurse activated the overhead lights, grabbed the fire extinguisher near the room entrance, and was able to quickly put out the fire. Once it was extinguished and the monitor setup examined, the culprit was identified: the leaking bag of saline into the active transformer. Fortunately, neither the patient nor any member of the operating staff was injured as a result of this incident. The damaged equipment was promptly replaced and the procedure concluded without further incident.