Why aren't surgical fires classed as a Never Event?
Nigel Roberts examines the evidence around the incidence of surgical fires, as well as current guidance to prevent associated harm. He considers whether surgical fires should be classed as a 'Never Event' and whether mitigating steps should be incorporated into the WHO surgical safety checklist
The research on the current three intra-operative 'Never Events' has bought to light another potential intra-operative 'Never Event' for discussion – surgical fires. 'Never Events' are defined as 'Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers'.1
Early research by Bruley2 concluded that 'surgical fires are a preventable hazard', five years prior to the publication of the World Health Organization's (WHO) surgical safety checklist. So why was the decision made not to class a surgical fire as a 'Never Event'?
Research suggests that the first recorded surgical fire, occurring on a patient as a result of the use of anaesthetic gases, goes as back as far as 1850 – when ether caught fire during facial surgery.3,4 However, surgical fires remain a significant safety issue today.
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