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Heat, Fuel, and Oxidizer Triangle: A Recipe for Disaster
By Sara Freiberg

In the 16 years that I worked in the operating room, I witnessed one small fire and one potential fire. The potential incident occurred when a resident removed an endoscope from an illuminated fiberoptic light cord and placed the illuminated cord directly on the patient drape. I turned and looked down to see a small heat ring forming on the drape. I immediately removed the cord, had the light source shut off, and shared with the resident the importance of always asking the circulator to shut off the light source off prior to disconnecting the scope and placing the cord in a safe area to cool. The resident was shocked and admitted he was never told this could occur.

The incident where a small fire did occur happened during a blepharoplasty procedure. The patient was sedated and awake. The doctor was teaching a resident during the procedure and was using a handheld, battery-operated, high-heat cautery pencil. As he used the cautery on the patient’s eye, he turned to speak to the resident and placed the hot tip of the cautery pencil next to the patient’s head. A flame immediately sparked on the drape and I grabbed a sponge, soaked it in saline, and doused the flame immediately. Luckily, the patient was not injured and, at the time, never even knew it occurred. I remember the surgeon and resident looked at me and I could see both the shock and relief in their eyes. It all happened so quickly. Both events were frightening, preventable, and reiterated the importance of monitoring the sterile field, instruments, devices, and systems used during a procedure at all times.

In 2011, the ECRI Institute estimated that between 550–650 surgical fires occurred annually in the U.S. Currently, they estimate that number has fallen to 200–240 surgical fires occurring annually in the U.S. While the numbers are decreasing, surgical fires remain a significant patient-safety hazard and can have devastating consequences for patients, staff, and the reputation of the healthcare facility. According to the FDA, a surgical fire can occur at any time when three specific elements are present: an oxidizer, such as oxygen or nitrous oxide; an ignition source, such as an electrocautery device; and a fuel source, such as surgical drapes, alcohol-based skin preps, or the patient’s hair, tissue, or skin. As the operating room is an oxygen-rich environment, a surgical fire can occur when all three elements of this fire triangle come together.1

The most common surgical fire locations are the patient airway (34%), face or head (28%), and elsewhere inside or on the patient (38%).2 In one event, a surgical patient suffered severe burns across her face and other parts of her body. The fire began when the doctor used an electrical surgical tool. An oxygen mask was being administered and oxygen had pooled under the drapes surrounding her face and caught fire, causing her face to catch fire. The patient stated she suffered second- and third-degree burns, dental injuries, and post-traumatic stress disorder. She has since undergone 18 additional surgeries to treat her injuries.3

According to an article in The Ochsner Journal, “Fire safety is not a topic on the top of most priority lists in the OR today, possibly because a great deal of misinformation exists regarding the subject. Some of the more common misconceptions are that OR fires do not happen in today’s hospitals; if fires do occur, they were not preventable; fires only occur at inferior facilities; and all staff in the OR know what to do if a fire occurs.”4

An anesthetized patient, lying on an OR table and strapped for safety, is not capable of his or her own care and relies solely on the surgical team members to ensure safe outcomes. In an OR, the surgeon provides the heat with items such as cautery, drills, or lasers; the circulating and scrub nurses control the fuel, which can be anything from prepping agents, drapes, sponges, or hair; and the anesthesiologist provides the oxygen. The potential for a surgical fire can only occur when all three sides of the triangle are present.

In addition to the risks of a fire on a patient, there is also the risk of a fire inside of the patient. In the U.S., airway fires account for two deaths each year and are also preventable adverse events. The oxygen-rich environment in the OR contains many combustible materials, including gauze sponges, drapes, towels, and tubing; and heat or ignition sources, including electrocautery, lasers, fiberoptic light sources, and endoscopes. Following are a few tips for preventing surgical fires. Additional contributing factors may be located in the OR resources section below.

Tips for preventing surgical fires (heat, fuel, oxidizer)
AORN defines fuel as anything that will burn. This also includes the patient.

Heat from electrocautery (ESU devices)

  • Keep in standby mode when not in use
  • Keep the active electrode tip clean
  • Keep ESU pencil off patient drapes
  • Keep electrocautery pencil in the holster after use
  • Confirm grounding pad is stable
  • If using a battery-operated, high-heat cautery, ensure it is cool before placing down

Heat from power drills and burrs

  • Ensure sufficient irrigation occurs
  • Adequate cooling of drill when drilling is complete
  • Refrain from placing drills on patient drapes

Heat from light cords

  • Inspect for damages
  • Shut off illuminated light source before disconnecting endoscopes
  • Keep illuminated light cords off patient drapes
  • Place light sources in standby mode and turn the unit off when not in use

Heat from instruments and devices

  • Inspect and test insulated instruments and cords (i.e., lap instruments, bipolar instruments, and all cords) before, during, and after all procedures for any holes, cracks, cuts, and damages.
  • Take out of service immediately until repair or replacement occurs.

Fuel from skin prep solutions

  • Prevent skin preps from pooling on patient.
  • Prep solutions with alcohol must be allowed to dry before draping the patient and allowing the surgery to begin (refer to skin prep drying directions).

Fuel from surgical cloth and paper drapes

  • Some drapes contain a degree of resistance to ignition when in ambient air, although they will burn in an oxygen-enriched environment.
  • Oxygen is heavier than air and can collect under surgical drapes in the head and neck area, so position drapes in a vertical manner in front of the patient’s face so oxygen will not become trapped around the head and neck area.


  • The OR is an oxygen-enriched atmosphere and exists whenever supplemental inhalation anesthesia is being used. Nitrous oxide also provides a combustion source, similar to oxygen.
  • Stop supplemental oxygen or nitrous before and during the use of an ignition source.
  • OR team members should evaluate whether supplemental oxygen is necessary for the patient, especially during procedures involving the head, neck, or upper-chest areas. For these cases, a closed oxygen-delivery system should be used (when possible, oxygen should not exceed 30%).
  • If the patient will require greater than 30% oxygen, the risk of fire increases. Team members should discuss how the surgical technique will be approached to minimize fire risk.

What can we do to increase awareness, communication, and protocols?
Operating room team members should be trained in recognizing and reducing the potential for surgical fires. Training should include factors that increase the risk of surgical fires, how to manage fires that do occur (both in and on the patient), periodic fire drills, how to use carbon dioxide (CO2) fire extinguishers, and evacuation procedures. The FDA launched an initiative called “Recommendations to Reduce Surgical Fires and Related Patient Injury” to increase awareness and encourage surgical teams to work together to adopt practices that will prevent fires from occurring. As part of the initiative, the FDA has issued six specific recommendations to help reduce surgical fire risk:

  1. Conduct a fire risk assessment
  2. Use supplemental oxygen safely
  3. Use alcohol-based skin prep agents safely
  4. Use surgical devices and equipment safely
  5. Communicate with surgical team members effectively
  6. Plan how to manage a surgical fire5

It is imperative that we work as a team and keep these three areas of the fire triangle separate from one another. Education, training, and awareness are essential. The surgical team should understand how fires can potentially start and how we can control heat, fuel, and oxygen sources. A surgical fire safety approach should involve all surgical team members and include team communications; discussing potential fire risk; and prevention steps prior to the procedure, in the presurgical checklist stage, in the time-out stage, and throughout the procedure. Learning from past events to prevent future reoccurrences is necessary for patient safety. Patients in surgery are depending on us to protect them from harm. Please refer to the OR resources links for additional tips, videos, and posters to share with your surgical teams.

Operating room resources

Patient fire stories:

To learn more about the FDA’s Preventing Surgical Fires Initiative, visit:

To learn more about ECRI tips for preventing and addressing surgical fires, visit: http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8197

Visit Anesthesia Patient Safety Foundation (APSF) and ECRI Institute’s downloadable video and printable posters and visual aids on how to prevent surgical fires:

OR Fire Prevention Algorithm poster
8.5×11 inches | 11×17 inches | 22×28 inches

OR Fire Prevention poster
8.5×11 inches | 11×17 inches | 22×28 inches
22×28 inches (with bleed)

OR Fire Prevention flyer – 2 pages
8.5×11 inches


  1. https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm282810.htm
  2. http://bulletin.facs.org/2013/08/preventing-surgical-fires/
  3. https://www.nbcwashington.com/investigations/Patients-Report-Suffering-Severe-Burns-From-Fires-During-Surgery-370846391.html
  4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096161/
  5. https://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm608637.htm






Sara Freiberg, CST, CBSPDT, CER, has more than 15 years experience working as a certified surgical technologist, with five of those years spent traveling to various operating rooms across the U.S. Following Sara’s time in the clinical arena, she worked as a surgical technology didactic and lab instructor at Rasmussen College. Sara holds bachelor degrees in science and business and marketing, which led to her work with various medical device companies as a clinical specialist, product manager, and clinical training manager. She has experience working on quality and regulatory teams, monitoring patient-adverse events, and postmarket surveillance activities.

Sara currently works for Northfield Medical as a clinical education manager where she provides education which is based on current manufacturer and regulatory guidelines regarding various healthcare topics for SPD, OR, and GI staff. Training entails the care and handling of medical devices to ensure patient safety, as well as targeted education addressing departmental cost concerns. Her passion is working with SPD, OR, and GI departments; providing assessments; and sharing best practices with respect to patient and staff safety, surgical instruments, and medical devices. Sara is a voting member of the AAMI ST/WG84, ST91 flexible endoscope committee, and she has developed several CEU presentations approved through CBSPD, CBRN, NCCT, and IAHCSMM. Sara also authors a biweekly healthcare article for Ultra Clean Systems.

Sara is currently studying for the Certification Infection Control (CIC) exam through APIC.

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