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Fire Safety: New Expectations for the OR and Procedure Areas

By Marty Piepoli, MSW, CHFM, HACP and Kimberly Merritt, RN, MHA, CNOR, HACP

With the adoption of the 2012 versions of the Life Safety Code 101 (LSC©) and the Health Facilities Code, NFPA99, 2012, the Joint Commission added expectations for how staff in the OR and Procedure areas would approach fire safety and particularly, the use of flammable germicides and antiseptics in these areas.  Effective this past January, Joint Commission revised an element of performance under Fire Safety Risks that speaks to clearly defining the roles and responsibilities at the point of the fire and away from the fire.  The LSC© refers to Section 18/ related to education and training for fire safety response.  As the adoption of the LSC© and NFPA99 moved forward, changes to guidance in the TJC standards has taken on a risk-based approach of the codes.  Therefore, increased emphasis has been applied to higher risk areas of the healthcare organizations, especially the OR and procedure rooms where there is a greater risk of fire.

The ECRI Institute estimates that 90-100 surgical fires occur each year in the United States. These fires are often related to precipitating factors, such as flammable germicides, antiseptics, linens, drapes, and electrical ignition sources.  Despite the issuance of Sentinel Event 29  by the Joint Commission (TJC), information from the Institute of Safe Medication Practices (ISMP) March 8, 2018 article and the fail-safe technologies that we have today, the risk of fires is still great.  The codes and standards are a guide to continued patient safety, however it seems they can sometimes contradict and/or create barriers to other areas of safe practice.

Effective January 1, 2018, TJC added standards that reference NFPA 99 and requires that when flammable germicides or antiseptics are used during surgeries utilizing cautery, laser, or electrosurgery, it is required that “Solution-soaked materials have been removed from the operating room prior to draping and use of surgical devices”.  This is contradictory to accepted OR standards of practice. This contradiction of practice has also been addressed by American Society of Health Care Engineering (ASHE), National Fire Protection Association (NFPA), TJC, ECRI, Becton Dickinson and the Centers for Medicare and Medicaid (CMS). Therefore, on Feb 12, 2019 Association of Operating Room Nurses (AORN) issued a statement regarding this practice and expectations. TJC also provided guidance to surveyors directing organizations to remove solution-soaked materials away from the patient vicinity.  In the meantime, the NFPA99, 2012 Code guidance is being reviewed to provide updated regulations on addressing flammable germicides in the OR and procedure area settings.

What should an organization do to maintain safe procedural areas? Make sure you perform a risk assessment to determine the solution-soaked items that must be removed, the distance they should be from the patient, and how they will be managed.  The focus is the safety of the patient and you will need to determine the appropriate practice of either removal away from the vicinity of the patient, the surgical field or removal from the procedural room.  It is also recommended that your safety officer and/or authority having jurisdiction (AHJ) review and approve the plan. To remain in compliance, organizations should have a facility fire safety assessment (EC.02.03.01 EP11) and perform a fire risk assessment for each patient that considers oxidizers, ignition and fuel source as recommended by the US Food and Drug Administration in JC Online June 6, 2018

Staff involved in the procedural areas and OR fire risk assessment should be able to associate the risk with appropriate actions to be taken with the assessed level of risk.  Fire safety education and organizational policy should be completed to delineate these actions.  When composing a policy, make sure all stakeholders, such as Cardiac Cath Lab, L&D, or any other areas that may use alcohol-based germicides, flammable solutions or antiseptics are involved.  All staff in procedural areas need to be aware of these risks and be able to take appropriate actions to keep the patient safe and prevent fires.

Stay tuned.  As more information and guidance on this topic evolves, C&A will keep you updated with the latest guidance.  For additional questions or concerns, contact is at Info@courtemanche-assocs.com.


  1. ECRI Institute. Supplement to: New clinical guide to surgical fire prevention: patients can catch fire—here’s how to keep them safer [guidance article]. Health Devices 2009 Oct; 38(10):314-32.
  2. The Joint Commission: Sentinel Event Alert, Preventing Surgical Fires, Issue 29, 6/24/03
  3. The Life Safety Code©, NFPA101, 2012 edition
  4. The Joint Commission Environment of Care Chapter 2019
  5. NFPA99, 2012, Section 15.13
  6. AORN Position Paper February 2019
  7. Clarke JR, Bruly ME. Surgical Fires: Trends associated with prevention efforts.  PA Patient Safety Advisor 2012; 9:130.
  8. CFR482.51 (b) Tag A-0951 Surgical Services, Publication 100-07, Transmittal 183, released October 12, 2018
  9. ISMP, Medication Safety Alert, Surgical Fires Caused by Skin Preps and Ointments: Rare but Dangerous and Preventable. Volume 23, Issue 5, March 8, 2018
  10. Joint Commission Online, FDA issue guidance on how to prevent surgical fires, June 6, 2018
Courtemanche & Associates Team

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