JPS Health Network received the 2013 Stand Up For Patient Safety Management Award from the National Patient Safety Foundation for a staff-driven quest to improve fire prevention in the operating room. The award recognizes “successful implementation of an outstanding patient safety initiative,” with evidence of patient safety improvement and involvement of staff at all levels.
Although relatively rare and never a problem at JPS, surgical fires are potentially devastating for both patients and hospitals. Because they are preventable, the FDA and other regulatory agencies have stepped up efforts to raise awareness of the hazardous trifecta present in the operating room — alcohol-based prep agents, open oxygen, and surgical equipment such as lasers and electrocautery units.
A group of nurses and techs at JPS took the initiative last year to turn a critical eye on existing policies and procedures, asking basic questions such as, “Does everyone know what to do if there a fire?” And, “Are we doing everything we can to prevent them?” said nurse Kathy Alexander, staff development coordinator in Perioperative Services. Having formed the Operating Room Fire Safety Committee, “we started looking at our policy and we said, ‘We can do better than that,’” she said.
The group latched onto a tool developed by the Association of periOperative Registered Nurses (AORN) to evaluate individual patient risk. The assessment tool includes five questions, including, Will an alcohol-based prep agent or other volatile chemical be used preoperatively? Will open oxygen or nitrous oxide be administered? Is an electrosurgical unit, laser or fiber-optic light cord being used? If the answer to any question is yes, preventive measures ensue. Risk can often be mitigated by simply preventing prep agents from pooling under a patient’s body, and allowing them to dry. Each patient’s assessment score follows them into the operating room and is announced before the procedure begins, raising awareness among everyone present.
“Though we had not experienced a fire in the O.R., everyone recognized that this initiative was a positive and important change to our standard of care to reduce the risk,” said Trudy Sanders, vice president of Patient Services.
In addition to Alexander, who also is president of the Fort Worth chapter of AORN, members of the committee included nurses Socorro Sanders, Lauren Smith, Deb Stuart and Lolita Yraola; and surgical techs Gladys Bowen, Catherine Killough and Ellen Schroeder.
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