Numerous examples exist of such practical and actionable knowledge: where surgeries take place around the neck and head, as Ms. Reuter's did, patients are at disproportionately greater risk, because cutting tools will be used in close proximity to where oxygen is delivered. Even outside of the operating room per se, surgicalfire.org reminds visitors that preventable burns can easily occur and easily go unreported. For example, transdermal delivery vehicles, such as nicotine patches, may become hot enough to administer serious burns when exposed to MRI radiation. Training MRI technicians and alerting patients to be cognizant of such details is all part of the group's educational agenda.

New hardware, new strategies.


Congress seems to be responding to the popular groundswell over this subject. Changes to Medicare payment structures that have been in debate since 2005 will finally become law later this year. These changes mandate that health care facilities that produce data on a range of safety and patient care concerns showing an improvement in the quality of those services can be awarded a 2% increase in payments, while those at the other end of the spectrum will suffer a 2% reduction. It is hoped that the financial incentive will help spur greater attention to fire and patient safety recommendations.

Efforts like these point out the need for training and teamwork across disciplines. The typical O/R triumvirate is a mirror of the fire triad, with anaesthesiologists handling the oxidizers, nurses in charge of propellants such as disinfectants and ointments and surgeons providing the spark with lasers and electrosurgical tools.

The group AORN (Association of periOperative Registered Nurses) has developed a tool kit free to all members, and presently in the hands of at least 13,000 operating-room directors and managers nationwide that emphasizes the role of teamwork and the need for standard procedures that compel every member of the O/R team to think beyond his or her specific role in the surgical process. As Patricia Seifert, editor-in-chief of the monthly AORN Journal writes, "the number one cause of fires is lousy communication."

Across the nation operating-room staffers are undergoing quarterly briefings by their institutions, aimed at reinforcing fire-prevention techniques. These include such simple practices as proper hand-off of high-heat cauterization tools so as to avoid ignition of blankets, paper and dressings. Such practices should be second nature, but the surge in new and unfamiliar technologies requires that current practitioners be periodically reacquainted with hardware devices coming more commonly into use. Even warmed blankets present a problem. A nurse may not feel the internal temperature of a blanket just out of an electrical warmer, before spreading it over a patient. About half of the hundreds of O/R malpractice suits that cite patient burns are from devices intended to keep the patient warm. About a third center on electrical tools used for cauterization.

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