Despite staff having a general understanding of fire risk in the surgical environment, Aurora BayCare Medical Center (ABMC) experienced a fire in the OR (with injury to a patient) in 2016. Fires in the OR are considered never events, and are reportable as sentinel events by the Joint Commission and other accrediting bodies. Following this event, a gap analysis showed that further education and practice change were necessary. Using the Plan-Do-Study-Act quality improvement model, a comprehensive educational plan was developed and implemented. Education was provided using both active and passive teaching methods, to ensure that meaningful learning would take place and knowledge retention would occur (Costello, 2017). Staff education consisted of PowerPoint lecture, policy review with quiz, participation in 2 simulation scenarios and review of computer based online learning modules.
The gap analysis also identified a practice issue, as we were not assessing the fire risk associated with each individual case. Staff had the general opinion that all surgical cases were at risk for fire, but did not identify those specific cases which posed an increased risk for fire in the OR. It was identified that the Association of Perioperative Registered Nurses [AORN] (2017), recommendations the use of the Fire Risk Assessment Score (FRAS), to identify those cases that posed a greater risk for fire in the OR and required additional safety measures be taken. The AORN fire risk assessment tool was adopted and implemented for all OR cases, and required the staff to score the case based on set criteria, and communicate the score and necessary additional safety measures during the “time-out” process. Aurora BayCare Medical Center first adopted this process on paper, and then took this to the system surgical committee for implementation into the electronic health record, across all 18 system hospitals.
The first fire safety simulation that staff participated in focused on general fire safety, risk factors for fire in the OR, mitigating risks, recognizing and reacting to a fire in the OR, extinguishing the fire, gas shut off, and evacuation. Simulation was used to bridge the gap between obtaining knowledge, and implementing what was learned into practice (Wilcox, Miller-Cribbs, Kientz, Carlson, and DeShea, 2017). The second fire safety simulation focused on the components of the FRAS, calculating the score and integrating the score into the “time-out” process. Post simulation staff surveys indicated that 85.39% of staff felt that the simulations were extremely helpful, and provided them with useful information that would help to prevent future incidents of fire in the OR.
Post educational intervention audits were done to assure that staff members were calculating the FRAS, discussing the FRAS during the “time-out” process and documenting the FRAS in the electronic health record. Audits did show that the FRAS was implemented successfully.
Fire safety education is an ongoing investment that helps to keep or staff and patients safe. Recommendations were made to have staff participate in fire safety simulations and review policy and procedure annually, to prevent any further incidents of fire in the OR at ABMC.
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