• B Rocos and L J Donaldson.
• National Patient Safety Agency, London, UK. brettrocos@gmail.com
• Ann R Coll Surg Engl. 2012 Mar 1; 94 (2): 87-9.

IntroductionSurgical fires are a rare but serious preventable safety risk in modern hospitals. Data from the US show that up to 650 surgical fires occur each year, with up to 5% causing death or serious harm. This study used the National Reporting and Learning Service (NRLS) database at the National Patient Safety Agency to explore whether spirit-based surgical skin preparation fluid contributes to the cause of surgical fires.MethodsThe NRLS database was interrogated for all incidents of surgical fires reported between 1 March 2004 and 1 March 2011. Each report was scrutinised manually to discover the cause of the fire.ResultsThirteen surgical fires were reported during the study period. Of these, 11 were found to be directly related to spirit-based surgical skin preparation or preparation soaked swabs and drapes.ConclusionsDespite manufacturer's instructions and warnings, surgical fires continue to occur. Guidance published in the UK and US states that spirit-based skin preparation solutions should continue to be used but sets out some precautions. It may be that fire risk should be included in pre-surgical World Health Organization checklists or in the surgical training curriculum. Surgical staff should be aware of the risk that spirit-based skin preparation fluids pose and should take action to minimise the chance of fire occurring.

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