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Based on observation, investigation, evidence and interview, the facility failed to have proper policies and procedures for the operating room in accordance with NFPA 101 LSC (00) Section 19.7.1.1. This deficient practice could affect the safety of patients undergoing certain types of surgeries.

Findings include:

On 08/02/2012 at 1:03 PM, a surgical fire occurred in Mercy Hospital's Operating Room #1. At the time of the fire, the patient was undergoing Left and Right Temporal Artery Biopsies. The patient was sedated by means of monitored anesthesia care and was receiving 100% oxygen via a non-rebreather mask at 10 liters per minute. Patient was completely covered by surgical drapes with only the temporal regions of the face exposed. The oxygen mask was located underneath the surgical drapes.

At the time of the fire, the OR staff included the surgeon, the nurse circulator, the nurse anesthetist and the certified surgical technician. According to observation, evidence and interviews, the biopsy sites were first ultrasounded using a non-flammable ultrasound gel. Then, a prep solution containing 10% Providone Iodine was applied to the site before the ultrasound gel was reapplied to confirm the location of the arteries. The surgeon completed the procedure on the left temporal artery and was working on the right temporal artery at the time of the fire.

According to the surgeon, he was using the electro surgical pencil on the right temporal artery when he witnessed a "spark or flame" appear at the patient's right cheekbone before the flame disappeared below the surgical drapes. The OR staff immediately removed the surgical drapes from the patient and doused the patient's face with approximately 1,500 cc of sterile water, then activated the nearest fire alarm pull station and called a "Code Red" in accordance with hospital policies. Once the patient's airway was verified by a pulmonologist to not be compromised, the patient was transferred to a burn unit for treatment.

Although the investigation revealed that the hospital's actions to suppress the fire were appropriate, the facility, at the time of the fire, failed to have policies and procedures in place addressing monitored anesthetic care, the use of electro surgical pencils in the presence of an oxygen enriched environment or the hazards associated with Surface Fiber Flame Propagation in accordance with nationally published reports outlining the associated hazards..

This deficient practice was verified by the Patient Safety Risk Manager for Mercy Hospital, at the time of the investigation.

Based on observation, investigation, evidence and interview, the facility failed to have proper policies and procedures for the operating room in accordance with NFPA 101 LSC (00) Section 19.7.1.1. This deficient practice could affect the safety of patients undergoing certain types of surgeries.

Findings include:

On 08/02/2012 at 1:03 PM, a surgical fire occurred in Mercy Hospital's Operating Room #1. At the time of the fire, the patient was undergoing Left and Right Temporal Artery Biopsies. The patient was sedated by means of monitored anesthesia care and was receiving 100% oxygen via a non-rebreather mask at 10 liters per minute. Patient was completely covered by surgical drapes with only the temporal regions of the face exposed. The oxygen mask was located underneath the surgical drapes.

At the time of the fire, the OR staff included the surgeon, the nurse circulator, the nurse anesthetist and the certified surgical technician. According to observation, evidence and interviews, the biopsy sites were first ultrasounded using a non-flammable ultrasound gel. Then, a prep solution containing 10% Providone Iodine was applied to the site before the ultrasound gel was reapplied to confirm the location of the arteries. The surgeon completed the procedure on the left temporal artery and was working on the right temporal artery at the time of the fire.

According to the surgeon, he was using the electro surgical pencil on the right temporal artery when he witnessed a "spark or flame" appear at the patient's right cheekbone before the flame disappeared below the surgical drapes. The OR staff immediately removed the surgical drapes from the patient and doused the patient's face with approximately 1,500 cc of sterile water, then activated the nearest fire alarm pull station and called a "Code Red" in accordance with hospital policies. Once the patient's airway was verified by a pulmonologist to not be compromised, the patient was transferred to a burn unit for treatment.

Although the investigation revealed that the hospital's actions to suppress the fire were appropriate, the facility, at the time of the fire, failed to have policies and procedures in place addressing monitored anesthetic care, the use of electro surgical pencils in the presence of an oxygen enriched environment or the hazards associated with Surface Fiber Flame Propagation in accordance with nationally published reports outlining the associated hazards..

This deficient practice was verified by the Patient Safety Risk Manager for Mercy Hospital, at the time of the investigation.