It was a chaotic scene in the operating room just moments before a critically ill patient at FirstHealth Moore Regional Hospital burst into flames. There was “lots of confusion,” a surgical technician later told hospital inspectors.
The patient who arrived at the emergency department in Pinehurst, N.C., in June 2013 needed an immediate tracheostomy. His grossly swollen tongue from an allergic reaction was preventing him from breathing. A surgeon was summoned from another operating room.
The surgeon “was standing there with knife in hand and he says, 'Somebody prep the patient,'” according to a CMS report on the incident. As blood gushed from the neck incision, the surgeon deployed an electric cauterizing tool. It ignited the alcohol-based disinfectant used at the incision site, leaving the patient with second-degree burns on his neck and shoulders.
Officials at the 379-bed hospital told inspectors that fire-prevention policies were in place. Yet that initial scramble in the operating room, as described in the report, led to violations of several well-established best practices for safe-equipment use to prevent surgical fires. They are included in the Preventing Surgical Fires Initiative, which has been aggressively pushed by the Food and Drug Administration for the past three years.
The hospital has since strengthened its fire-safety rules, including banning alcohol sterilizers in most emergency procedures. The surgical team “responded to the incident appropriately” and finished the operation after putting out the fire, FirstHealth of the Carolinas CEO David Kilarski said in a statement.
Despite a slew of news accounts about patients being set on fire in operating rooms across the country, adoption of precautionary measures has been slow, often implemented only after a hospital experiences an accident. Advocates say it's not clear how many hospitals have instituted the available protocols, and no national safety authority tracks the frequency of surgical fires, which are thought to injure patients in one of every three incidents. About 240 surgical fires occur every year, according to rough estimates by the ECRI Institute, a not-for-profit organization that conducts research on patient-safety issues. But fires may be underreported because of fear of litigation or bad publicity.