Running head: LEADERSHIP STRATEGY ANALYSIS
Leadership Strategy Analysis
Fire Prevention in the OR
Allyson Grutter
Ferris State University
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Abstract
Surgical fires affect hundreds of patients each year in the United States. Surgical fire safety is an
important component to every operating room and it is important that surgical teams have proper
training and tools to ensure patient safety. A recent surgical fire in our department made us
aware of a need for improvement in this area of our practice. An interdisciplinary quality
improvement team was established to analyze data and determine specific outcomes that will
ensure patient safety. The team utilized research and evidence based practice from the
Association of peri-Operative Registered Nurses (AORN), The Emergency Care Research
Institute (ECRI), and the Anesthesia Patient Safety Foundation (APSF) to determine what
outcomes were most important in surgical fire safety.
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Fire Prevention in the OR
Surgical fires are defined as fires that occur in, on, or around a patient during a surgical
procedure (U.S. Food and Drug Administration, 2012). It is estimated that between 550 and 650
surgical fires occur in the United States each year (2012). Surgical fires are considered sentinel
events, which means these events should never occur in a healthcare setting. Yoder-Wise (2011)
lists fires as one of the top twenty most common healthcare sentinel events. Healthcare
organizations must develop policies, tools, and regulations to ensure these events never occur
inside their operating rooms. As a result of a recent surgical fire in our department, it has become
aware that we have a need for quality improvement in this area of our practice. Quality
improvement efforts are intended to prevent errors or identify areas of practice that need to be
reviewed in an effort to prevent errors and keep patients safe (2011). Maintaining quality care
and improving patient outcomes is imperative for the success of our business and continued
quality improvement efforts help maintain these high standards.
Problem Identification
The quality improvement process begins with the identification of an area of practice that
needs to be reviewed (Yoder-Wise, 2011). Our department experienced a surgical fire in June
that affected a pediatric patient. This unfortunate and preventable event brought many key issues
to light. The Emergency Care Research Institute (ECRI), an independent, not-for-profit
organization that researches best patient care practices, collaborated with the Anesthesia Patient
Safety Foundation (APSF) in 2009 to release important changes to the surgical fire prevention
recommendations. They outlined specific guidelines that peri-operative team members should
follow during surgical procedures including such recommendations as the amount of oxygen
content delivered during each case (ECRI Institute, 2009b). The ECRI Institute also outlines the
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importance of communication and the types of observations staff should be discussing prior to
the start of each procedure (ECRI Institute, 2009a) Our department does not utilize a specific
fire risk assessment at this time and, when fire breaks out, every second counts. Even though
fires are rare, their consequences can cause catastrophic problems such as disfigurement and
even death. It is for these reasons that fire prevention efforts must be reviewed, analyzed, and
updated to ensure that we are utilizing the best patient care efforts in our practice.
Interdisciplinary Team
Fire safety is the responsibility of each person in the operating room. With that in mind, it
is imperative that each role within the surgical team have representation. The Quality
Improvement (QI) team will consist of a member from each group including a surgeon, an
anesthesiologist, circulating nurse, and surgical technologist. Also included in the QI team will
be the surgical services educator, surgical services manager, and the director of anesthesia. The
team members were selected based on some of the key factors influencing the risk factors for fire
in the operating room. One of the risk factors is the use of oxygen and/or nitrous oxide during a
surgical procedure (Stanton, 2011). Most often, it is the anesthesiologists that control the amount
and duration of gases during a surgical procedure and thus play a major role in fire prevention
during the surgical procedure. Registered nurses also deliver oxygen during conscious sedation
procedures which often times are procedures involving areas of the head, neck, and face.
Surgical procedures occurring above the xiphoid process also increase the risk of fire during a
surgical procedure (Stanton, 2011). The surgical technologist is at the sterile field directly
observing the draping techniques and use of electro-cautery during the procedure. Non-occlusive
draping that allows high concentrations of oxygen to the surgical field where electro-cautery,
lasers, or fiber optic lighting is being used pose a risk for starting a fire (Stanton, 2011). The
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surgeon plays one of the biggest roles in preventing fires in the operating room. The surgeon
determines which surgical prep solution is to be utilized, when electro-cautery is being used, and
the way the drapes are placed during the procedure, all of which play a role in the potential for
surgical fires (2011).
Our surgical services educator and surgical services manager will help guide the change
process and be key in the implementation of any changes made as a result of the quality
improvement process. The director of anesthesia will oversee the implementation of any changes
among the anesthesia providers as they are not employees of the hospital but contracted by the
hospital. Each of these team members will communicate with their staff regarding the quality
improvement process and what the staff role will be in the process as well as after the process
has been completed (Yoder-Wise. 2011). This broad representation reflects a cross section of
team members that are affected by the problem and subsequently will have a role in the success
of the quality improvement (Yoder-Wise, 2011).
Data Collection
The first step in the data collection process was to determine the risk factors for fire that
existed in our operating rooms. Each surgical procedure performed over the course of one week
was evaluated for the most common risk factors of surgical fires and included the use of alcohol
based prep solutions, enriched oxygen and nitrous oxide environments, non-occlusive draping,
use of electro-cautery sources including lasers and fiber optic light sources, and procedures that
occur above the xiphoid process. The quality improvement team then used a Pareto chart to
present the data that was collected (See Appendix A). We chose the Pareto chart because it
reflects the major components of a quality control problem (Yoder-Wise, 2011). The visual
aspect of the chart allows the highest frequency of risk factors to be shown in descending order
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from left to right and can act as a guide to which factors we should concentrate on first (2011).
One of the most alarming trends was that key risk factors, such as use of oxygen or nitrous and
electro-cautery use, exist in nearly every surgical procedure yet these risk factors are not
currently being addressed in the surgical time-out to make certain all staff members are aware of
them.
Establishing Outcomes
The next step in the quality improvement process is to determine what efforts are needed
to improve the issues brought forth after analyzing the data. In the surgical setting, the
Association of peri-Operative Registered Nurses (AORN) guides our standards of practice. The
AORN has established a Fire Safety Tool kit that reflects the recommendations made by ECRI
Institute as well as the AORN (Stanton, 2010). Some of the recommendations include
implementing a fire risk assessment checklist, expanded fire drill scenarios, an updated fire
safety policy and procedure, an updated fire safety competency evaluation tool, a new fire safety
presentation for staff education, and links to fire safety resources (2010).
Nursing sensitive outcomes.
Based on the data we collected, and the recommendations from the AORN, we have
decided to establish some nursing-sensitive outcomes. We will begin a yearly fire safety
competency for all staff members working in surgical services. This competency will include
educational recommendations from AORN including videos, PowerPoint presentations, and a
subsequent test that must be passed with a score of greater than 80% to be considered in
compliance with this initiative.
We will also include a fire risk assessment in the surgical time-out prior to the start of
each surgical procedure. In determining what to include in the fire risk assessment, we looked at
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suggestions from the AORN, U.S. Food and Drug Administration, assessments utilized by other
surgical organizations, as well as suggestions from other healthcare advisory groups and
governmental agencies. As a result, we decided upon a fire risk assessment that is concise and
effective in preparing the surgical staff for potential hazards during the procedure (See Appendix
B). This fire risk assessment includes actions to be taken based on the fire risk assessment score.
Strategy Implementation
To allow sufficient time to build the risk assessment into our practice and electronic
medical record, we have set a “Go Live” date of January 2nd, 2013. The quality improvement
team will use the “ADKAR” model for change management to implement the fire safety quality
initiatives. We felt this model would be most effective because it is designed to help employees
transition through the change process as well as aid leadership in developing a change
management plan for the staff (Change Management Learning Center, 2007). The people
dimension of change of the ADKAR model is a critical component to ensure successful
implementation of the fire safety initiatives. The Quality Improvement (QI) team must
effectively manage the five key goals of the people dimension of change which include the
awareness of a need for change, desire to participate and support the change, knowledge of how
to change, ability to implement the change, and reinforcement to keep the change (2007). Staff
meetings have already taken place as a follow up to the surgical fire incident that occurred in
June. Those meetings resulted in staff awareness of a need for process improvement in the area
of surgical fire safety. A line of communication was formed and several discussions have taken
place with all members of surgical services. Awareness of a need for change can lend itself to a
desire to make the change. Awareness and desire are critical for success of change management
(2007).
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The QI team must then take steps to ensure the staff understands what the changes will
mean for them and make sure staff feels they have the tools and knowledge needed to implement
the change. Once knowledge and ability have been established, it is time to reinforce the changes
made. While resistance may be a primary response due to the fact that staff may feel burdened by
the extra steps of the fire risk assessment, maintaining open communication and offering support
can help staff overcome the initial resistance to the change.
Evaluation
Our team will be performing monthly audits as one way to ensure the new outcomes are
being met. We will perform random audits in the operating rooms to ensure fire risk assessments
are being performed prior to the start of each procedure. The room audits will help identify that
staff has the knowledge and tools to properly perform the assessments. Chart audits will also be
analyzed to determine if assessment are being performed and charted. The chart audits will be
measured against the live room audits to guarantee that the assessments being charted are
actually being performed. Yoder-Wise (2011) states that system improvements sometimes lead
to new problems and revisions may need to be made. Therefore, the audits will also be used to
identify any problems that have arisen inadvertently as a result of the newly implemented
strategies.
Conclusion
Quality management is geared toward improving the system and not assigning blame
when a part of that system has failed (Yoder-Wise, 2011). A surgical fire is a devastating
experience for all those involved. The fire experience in our operating room brought to light the
need for a process improvement. The multi-disciplinary quality improvement team analyzed data
and established a new standard within the operating room to ensure patient safety.
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Implementation of the new outcomes will require each team member to acknowledge and
support the change and work with the QI team to make the change successful. Every team
member in the operating room plays an important role in fire safety and this quality improvement
initiative will further enable staff to maintain impeccable patient safety records.
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References
Association of periOperative Registered Nurses. (2012). Fire Safety Tool Kit. Retrieved from
http://www.aorn.org/Clinical_Practice/ToolKits/Fire_Safety_Tool_Kit/Fire_Safety_Tool
_Kit.aspx#axzz29t7KWBC4
Change Management Learning Center. (2007). "ADKAR" - a model for change management:
Change management tutorial series. Retrieved from http://www.changemanagement.com/tutorial-adkar-overview.htm
ECRI Institute. (2009a). New clinical guide to surgical fire prevention. Health Devices, 38(10),
319-319. Retrieved from
https://www.ecri.org/Documents/Surgical_Fire_Poster%282009%29.pdf
ECRI Institute. (2009b). Preventing surgical fires: Important new recommendations released.
Retrieved from
https://www.ecri.org/Press/Pages/Preventing_Surgical_Fires.aspx?j=10275710&e=itsikit
as@outpatientsurgery.net&l=861900_HTML&u=106095094&mid=70600&jb=0
Stanton, C. (2011). Know your part in fire prevention. AORN, 94(4), C5-C6. Retrieved from
http://ac.els-cdn.com/S000120921100963X/1-s2.0-S000120921100963Xmain.pdf?_tid=19461128-2126-11e2-ad6e00000aacb361&acdnat=1351446009_0035af3ce132e175e3b7de3024a7a542
United States Department of Veteran Affairs. (2010). Surgical fire risk assessment protocol.
Retrieved from
http://www.patientsafety.gov/TIPS/Docs/SFSurgicalFireRiskAssessmnet.pdf
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U.S. Food and Drug Administration. (2012). Preventing Surgical Fires. Retrieved from
http://www.fda.gov/Drugs/DrugSafety/SafeUseInitiative/PreventingSurgicalFires/default.
htm
Yoder-Wise, P. S. (2011). Leading and managing in nursing (5 ed.). St. Louis, MO:
Elselvier:Mosby.
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Appendix A
Number of Procedures
Factors Increasing Fire Risk in the OR
180
160
140
120
100
80
60
40
20
0
Count
Use of oxygen or Use of electro
nitrous
cautery, laser, or
fiber optic light
cord
Use of alcohol
based prep
Procedure above
Use of Nonxiphoid process occlusive Draping
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Appendix B
(United States Department of Veteran Affairs, 2010)