Official reprint from UpToDate®
www.uptodate.com ©2018 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Fire safety in the operating room

Charles E Cowles, Jr, MD, MBA
Section Editor
Joyce A Wahr, MD, FAHA
Deputy Editor
Nancy A Nussmeier, MD, FAHA


Fire in the operating room (OR) is a relatively rare event, but when it does occur the medical outcomes are often catastrophic for the injured patient, with severe legal and economic consequences for the surgical team and facility.

Most OR fires are preventable with communication, appropriate education, and management of risks. Since these preventive measures have little cost and are nearly 100 percent effective, they are prioritized in patient safety initiatives.

This topic will review causes, high-risk settings, and prevention of fires in the OR, as well as acute management of a surgical fire and the burned patient. An outline of resources is provided for further details regarding education of OR personnel in the causes and prevention of OR fires.


Incidence — Reports of occurrence of operating room (OR) fires range from 217 to 650 events each year in the United States [1]. Since half of the states do not have mandatory reporting, the actual number is probably higher. Most claims occur in an outpatient setting (76 percent), involve the upper body (85 percent), and are cases managed with monitored anesthetic care (MAC) (81 percent) [2].

Impact — Patient injuries after an OR fire are often severe (eg, painful and disfiguring burns to face and neck or severe airway injury with tracheostomy and permanent lung damage) [2]. Typically, a surviving patient must return to the OR many times to treat acute burn injuries and revise scar tissue, causing recurring anxiety, post-traumatic stress, and economic burden [2,3].

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Dec 2017. | This topic last updated: Dec 02, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2018 UpToDate, Inc.
  1. Clarke JR, Bruley ME. Surgical fires: Trends associated with prevention efforts. Pa Patient Saf Advis 2012; 9:130.
  2. Mehta SP, Bhananker SM, Posner KL, Domino KB. Operating room fires: a closed claims analysis. Anesthesiology 2013; 118:1133.
  3. Dalal PK, Saha R, Agarwal M. Psychiatric aspects of burn. Indian J Plast Surg 2010; 43:S136.
  4. www.wenatcheeworld.com/news/2013/dec/06/botched-surgery-will-cost-hospital/ (Accessed on April 15, 2015).
  5. Wolf GL, Sidebotham GW, Lazard JL, Charchaflieh JG. Laser ignition of surgical drape materials in air, 50% oxygen, and 95% oxygen. Anesthesiology 2004; 100:1167.
  6. Greco RJ, Gonzalez R, Johnson P, et al. Potential dangers of oxygen supplementation during facial surgery. Plast Reconstr Surg 1995; 95:978.
  7. Laser ignition of surgical drapes. Health Devices 1992; 21:15.
  8. Epstein RH, Brummett RR Jr, Lask GP. Incendiary potential of the flash-lamp pumped 585-nm tunable dye laser. Anesth Analg 1990; 71:171.
  9. Treyve E, Yarington CT Jr, Thompson GE. Incendiary characteristics of endotracheal tubes with the carbon dioxide laser. An experimental study. Ann Otol Rhinol Laryngol 1981; 90:328.
  10. Goldberg J. Brief laboratory report: surgical drape flammability. AANA J 2006; 74:352.
  11. Barker SJ, Polson JS. Fire in the operating room: a case report and laboratory study. Anesth Analg 2001; 93:960.
  12. Roy S, Smith LP. What does it take to start an oropharyngeal fire? Oxygen requirements to start fires in the operating room. Int J Pediatr Otorhinolaryngol 2011; 75:227.
  13. Culp WC Jr, Kimbrough BA, Luna S. Flammability of surgical drapes and materials in varying concentrations of oxygen. Anesthesiology 2013; 119:770.
  14. Culp WC Jr, Kimbrough BA, Luna S, Maguddayao AJ. Operating room fire prevention: creating an electrosurgical unit fire safety device. Ann Surg 2014; 260:214.
  15. Di Pierro GB, Besmer I, Hefermehl LJ, et al. Intra-abdominal fire due to insufflating oxygen instead of carbon dioxide during robot-assisted radical prostatectomy: case report and literature review. Eur Urol 2010; 58:626.
  16. Shadangi BK, Khanna S, Mehta Y. Wrong gas: Risk of intra-abdominal fire during laparoscopic surgery. Indian J Anaesth 2012; 56:599.
  17. Hoshijima H, Takeuchi R, Sato E, Kikuchi H. [Accidental skin burns by fire of an antiseptic agent ignition by the spark of electric cautery]. Masui 2010; 59:1438.
  18. Wolf GL, Simpson JI. Flammability of endotracheal tubes in oxygen and nitrous oxide enriched atmosphere. Anesthesiology 1987; 67:236.
  19. Simpson JI, Wolf GL, Rosen A, et al. The oxygen and nitrous oxide indices of flammability of endotracheal tubes determined by laser ignition. Laryngoscope 1991; 101:981.
  20. Cowles CE, Chang JL. Flammable surgical preps require vigilance. APSF Newsletter 2014; 29:25.
  21. Apfelbaum JL, Caplan RA, Barker SJ, et al. Practice advisory for the prevention and management of operating room fires: an updated report by the American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology 2013; 118:271.
  22. Batra S, Gupta R. Alcohol based surgical prep solution and the risk of fire in the operating room: a case report. Patient Saf Surg 2008; 2:10.
  23. Tooher R, Maddern GJ, Simpson J. Surgical fires and alcohol-based skin preparations. ANZ J Surg 2004; 74:382.
  24. Fire hazard created by the misuse of DuraPrep solution. Health Devices 1998; 27:400.
  25. Hurt TL, Schweich PJ. Do not get burned: preventing iatrogenic fires and burns in the emergency department. Pediatr Emerg Care 2003; 19:255.
  26. Prasad R, Quezado Z, St Andre A, O'Grady NP. Fires in the operating room and intensive care unit: awareness is the key to prevention. Anesth Analg 2006; 102:172.
  27. Shah SC. Correspondence: Operating room flash fire. Anesth Analg 1974; 53:288.
  28. Weber SM, Hargunani CA, Wax MK. DuraPrep and the risk of fire during tracheostomy. Head Neck 2006; 28:649.
  29. Jones EL, Overbey DM, Chapman BC, et al. Operating Room Fires and Surgical Skin Preparation. J Am Coll Surg 2017; 225:160.
  30. Robinson JA. Denatured Alcohol. Quarterly of the NFPA 1907; 1:20.
  31. Somers-Dehaney A, Christie J. OR fire occurs in absence of oxygen enriched environment: A case report. APSF Newsletter 2008; 23:8.
  32. Fires from oxygen use during head and neck surgery. Health Devices 1995; 24:155.
  33. ECRI Institute. New clinical guide to surgical fire prevention. Patients can catch fire--here's how to keep them safer. Health Devices 2009; 38:314.
  34. Kim JB, Jung HJ, Im KS. Operating room fire using an alcohol-based skin preparation but without electrocautery. Can J Anaesth 2013; 60:413.
  35. Mathias JM. Scoring fire risk for surgical patients. OR Manager 2006; 22:19.
  36. Stoelting RK, Feldman JM, Cowles CE, Bruley ME. Surgical fire injuries continue to occur: Prevention may require more cautious use of oxygen. APSF Newsletter 2012; 26:41.
  37. Greenberg CC, Regenbogen SE, Studdert DM, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg 2007; 204:533.
  38. Rogers SO Jr, Gawande AA, Kwaan M, et al. Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery 2006; 140:25.
  39. Haynes AB, Weiser TG, Berry WR, et al. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf 2011; 20:102.
  40. Weiser TG, Haynes AB, Dziekan G, et al. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg 2010; 251:976.
  41. Neatrour GP, Lederman IR. Reducing fire hazard during ophthalmic surgery by using compressed air. Ophthalmic Surg 1989; 20:430.
  42. Kung TA, Kong SW, Aliu O, et al. Effects of vacuum suctioning and strategic drape tenting on oxygen concentration in a simulated surgical field. J Clin Anesth 2016; 28:56.
  43. American Society of Anesthesiologists Task Force on Operating Room Fires, Caplan RA, Barker SJ, et al. Practice advisory for the prevention and management of operating room fires. Anesthesiology 2008; 108:786.
  44. www.apsf.org/resources_safety.php (Accessed on April 15, 2015).
  45. Remz M, Luria I, Gravenstein M, et al. Prevention of airway fires: do not overlook the expired oxygen concentration. Anesth Analg 2013; 117:1172.
  46. Laser contact tips and tracheal tubes. Health Devices 1992; 21:18.
  47. Ossoff RH, Duncavage JA, Eisenman TS, Karlan MS. Comparison of tracheal damage from laser-ignited endotracheal tube fires. Ann Otol Rhinol Laryngol 1983; 92:333.
  48. Patel KF, Hicks JN. Prevention of fire hazards associated with use of carbon dioxide lasers. Anesth Analg 1981; 60:885.
  49. Sosis MB, Braverman B. Evaluation of foil coverings for protecting plastic endotracheal tubes from the potassium-titanyl-phosphate laser. Anesth Analg 1993; 77:589.
  50. Sosis MB, Braverman B. Prevention of cautery-induced airway fires with special endotracheal tubes. Anesth Analg 1993; 77:846.
  51. Sosis MB, Caldarelli D. Evaluation of a new ceramic endotracheal tube for laser airway surgery. Otolaryngol Head Neck Surg 1992; 107:601.
  52. Sosis MB, Dillon FX. A comparison of CO2 laser ignition of the Xomed, plastic, and rubber endotracheal tubes. Anesth Analg 1993; 76:391.
  53. Sosis MB. Which is the safest endotracheal tube for use with the CO2 laser? A comparative study. J Clin Anesth 1992; 4:217.
  54. Sosis MB, Braverman B, Caldarelli DD. Evaluation of a new laser-resistant fabric and copper foil-wrapped endotracheal tube. Laryngoscope 1996; 106:842.
  55. Sosis MB. Evaluation of five metallic tapes for protection of endotracheal tubes during CO2 laser surgery. Anesth Analg 1989; 68:392.
  56. Simpson JI, Schiff GA, Wolf GL. The effect of helium on endotracheal tube flammability. Anesthesiology 1990; 73:538.
  57. Rocos B, Donaldson LJ. Alcohol skin preparation causes surgical fires. Ann R Coll Surg Engl 2012; 94:87.
  58. NFPA 99 Health Care Facilities Code. National Fire Protection Association, 2015.
  59. NFPA 99.4.1 Risk Categories. NFPA 99: Health Care Facilities Code, 2018 Edition. NFPA (© 2017).
  60. NFPA 10, Standard for portable fire extinguishers. Chapter 5.2. National Fire Protection Association, 2010.
  61. Himmel HM. Mechanisms involved in cardiac sensitization by volatile anesthetics: general applicability to halogenated hydrocarbons? Crit Rev Toxicol 2008; 38:773.
  62. Vinegar A. Modeling cardiac sensitization potential of humans exposed to Halon 1301 or Halon 1211 aboard aircraft. Aviat Space Environ Med 2001; 72:928.
  63. www.apsf.org/resources/fire-safety/ (Accessed on April 15, 2015).
  64. www.aorn.org/toolkits/firesafety/ (Accessed on April 15, 2015).
  65. www.fuseprogram.org/ (Accessed on April 15, 2015).
  66. www.fesdidactic.org (Accessed on October 07, 2015).
  67. www.nfpa.org/safety-information/fire-prevention-week/about-fire-prevention-week (Accessed on April 15, 2015).
  68. NFPA 101 Life Safety Code. National Fire Protection Association, 2012.
  69. www.nfpa.org (Accessed on April 15, 2015).
  70. www.fda.gov/Drugs/DrugSafety/SafeUseInitiative/PreventingSurgicalFires/ (Accessed on April 15, 2015).
  71. www.jointcommission.org/sentinel_event_alert_issue_29_preventing_surgical_fires/ (Accessed on April 15, 2015).
  72. Standard EC.02.03.01. The Joint Commission, 2012.
  73. Standard EC.02.03.03. The Joint Commission, 2012.
  74. Standard EC.04.01.01. The Joint Commission, 2012.
  75. Comprehensive Accreditation Manual for Ambulatory Care of the Joint Commission. http://www.jointcommission.org/assets/1/18/2011_ahc_hdbk.pdf (Accessed on September 20, 2015).
Topic Outline