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TJC Suggested Actions for Preventing Surgical Fires

November 17, 2023

TJC Suggested Actions for Preventing Surgical Fires
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The Joint Commission (TJC) recently published a Sentinel Event Alert newsletter with updated information about preventing surgical fires. It states, "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."

The Alert also includes details about six suggested actions to prevent surgical fires. The suggested action topics are:

  1. Ensure that the time-out includes a robust fire risk assessment (FRA) for each surgical and endoscopic procedure.
  2. Anesthesia should maintain the local oxygen concentration at less than 30%, whenever possible.
  3. Carefully manage electrosurgical devices, light sources and cables, surgical draping, and other risks during a procedure.
  4. Provide training to operating room staff on how to avoid and manage fires and conduct fire drills.
  5. Report all surgical fires into your facility’s incident reporting system. 
  6. Encourage education of all operating room personnel/team members about the risk of surgical fires.

To learn more about this updated TJC guidance, read this Sentinel Event Alert.


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