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Alcohol skin preparation causes surgical fires.

Publication ,  Journal Article
Rocos, B; Donaldson, LJ
Published in: Ann R Coll Surg Engl
March 2012

INTRODUCTION: Surgical 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. METHODS: The 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. RESULTS: Thirteen 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. CONCLUSIONS: Despite 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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Published In

Ann R Coll Surg Engl

DOI

EISSN

1478-7083

Publication Date

March 2012

Volume

94

Issue

2

Start / End Page

87 / 89

Location

England

Related Subject Headings

  • Surgical Procedures, Operative
  • Surgery
  • Safety Management
  • Risk Factors
  • Preoperative Care
  • Patient Safety
  • Operating Rooms
  • Humans
  • Fires
  • Anti-Infective Agents, Local
 

Citation

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Rocos, B., & Donaldson, L. J. (2012). Alcohol skin preparation causes surgical fires. Ann R Coll Surg Engl, 94(2), 87–89. https://doi.org/10.1308/003588412X13171221501221
Rocos, B., and L. J. Donaldson. “Alcohol skin preparation causes surgical fires.Ann R Coll Surg Engl 94, no. 2 (March 2012): 87–89. https://doi.org/10.1308/003588412X13171221501221.
Rocos B, Donaldson LJ. Alcohol skin preparation causes surgical fires. Ann R Coll Surg Engl. 2012 Mar;94(2):87–9.
Rocos, B., and L. J. Donaldson. “Alcohol skin preparation causes surgical fires.Ann R Coll Surg Engl, vol. 94, no. 2, Mar. 2012, pp. 87–89. Pubmed, doi:10.1308/003588412X13171221501221.
Rocos B, Donaldson LJ. Alcohol skin preparation causes surgical fires. Ann R Coll Surg Engl. 2012 Mar;94(2):87–89.

Published In

Ann R Coll Surg Engl

DOI

EISSN

1478-7083

Publication Date

March 2012

Volume

94

Issue

2

Start / End Page

87 / 89

Location

England

Related Subject Headings

  • Surgical Procedures, Operative
  • Surgery
  • Safety Management
  • Risk Factors
  • Preoperative Care
  • Patient Safety
  • Operating Rooms
  • Humans
  • Fires
  • Anti-Infective Agents, Local