Sentinel Event Alert 68: Updating surgical fire prevention for the 21st century

Surgical fires continue to occur and represent a significant risk to patients and healthcare professionals. This Sentinel Event Alert provides updated information and replaces one on this topic that published in 2003. The Joint Commission issues this alert to help healthcare organizations recommit to surgical fire prevention. Most surgical fires and burns are associated with the use of an electrosurgical device while performing head and neck surgery. 

Surgical fires can be prevented by creating awareness of and carefully monitoring elements of the “fire triangle:” 1) oxygen, 2) ignition sources and 3) fuel.