Authors (including presenting author) :
Yiu IKW(1), Wong MC(1), Wong CW(1), Tse KC(1), Ho CH(1), Tsung PPK(1), Lee CK(1)
Affiliation :
(1) Operating Theatre, Prince of Wales Hospital
Keyword 1: :
Surgical Fire
Keyword 2: :
High Fire Risk
Keyword 3: :
Patient safety
Introduction :
Four significant Surgical Fire (SF)-related incidents were reported in the New Territories East Cluster (NTEC), resulting in injuries to both patients and staff. In one case, a patient sustained second-degree burns on the upper lip, while another case suffered burns on the chest wall. A fatal SF incident was also reported, alongside an incident where a surgeon sustained burns on his palm. These incidents highlight the severe consequences of SF, which not only endanger patients but also pose risks to Operating Theatre (OT) staff. The selection of this topic underscores the urgent need to raise awareness about SF and improve safety protocols. These cases revealed gaps in staff knowledge and competence, emphasizing the importance of enhancing preventive measures during high fire-risk procedures in the OT. A root-cause analysis of these incidents identified several contributing factors. One major issue was insufficient drying time for flammable alcohol-based skin disinfectants before surgical procedures began, significantly increasing SF risks. Additionally, the use of high-energy electrosurgical units (ESU) above the xiphoid in an oxygen-enriched environment further elevated the likelihood of fire outbreaks. Miscommunication among team members regarding ESU energy levels exacerbated the situation. Another critical factor was the inadequate training provided to junior staff and newcomers, many of whom lacked awareness of SF risks and were unable to identify high fire-risk procedures. This knowledge gap jeopardized both patient and staff safety. By addressing these issues through improved training, clearer communication, and optimized workflows, the risk of SF can be significantly reduced.
Objectives :
1. To evaluate current practices on SF prevention by conducting a thorough risk review of guidelines and protocols to re-address the risk of SF in the OT. 2. To enhance OT nursing staff compliance with SF prevention measures through educational sessions (ES) and scenario-based training (SBT). 3. To ensure the sustainability of new practices in department by periodically checking compliance with SF prevention measures.
Methodology :
Our project followed a structured timeline using the Plan-Do-Check-Act framework. 1. Plan phase: Reviewed current practices and guidelines, conducted a pre-survey to gather baseline data, and identified service gaps. Developed implementation plan and obtained managerial approval, including the design of the High Fire Risk Box and the workflow checklist for high fire-risk cases. 2. Do phase: Implemented the program by conducting a pretest, followed by ES and SBT. Introduced High Fire Risk Box and workflow checklist to enhance understanding and compliance. 3. Check phase: Collected post-test data to evaluate selected OT nursing participants’ understanding and improvement. Conducted On-site spot checks to assess staff performance in using the High Fire Risk Box and checklist. 4. Act phase: Reviewed feedback and performance evaluations to refine the program. Regular updates were provided to the Department Operations Manager (DOM), Nursing Consultant (NC), Ward Managers (WM), and Advanced Practice Nurses (APN) to seek their input for further improvements. To ensure sustainability, ongoing support was provided to staff, and the use of the High Fire Risk Box and Checklist was actively promoted. The ES and SBT were also approved for inclusion in the orientation program for new OT staff.
Result & Outcome :
To evaluate the adoption of new high fire risk measures, surprise checks were conducted in ENT, neurosurgery, and eye surgery specialties during the observation phase. Eight cases were observed using convenience sampling. In all cases, staff successfully utilised the high fire risk box and displayed the required signage. The program employs a multi-approach strategy, combining educational sessions, feedback collection, and simulation-based training with return demonstrations to reinforce skills. Upon the first phase of implementation, the High Fire Risk Box has been implemented in the ENT, Eye, and Neurosurgery teams since 12/2024, this project has been extended to the Emergency Theatre to enhance patient safety in emergency settings from 9/2025. There are no surgical fire incident since the program implemented in PWH OT and throughout completed High Fire Risk checklist are all correct. Ongoing assessments ensure competency, and the High Fire Risk Box promotes consistent safety practices.
