There are a few things that should never happen in an operating room. When it comes to surgerical mistakes, most people think about foreign objects left in a patient or wrong-side surgeries. These are "never" events that just don't seem possible, but they do happen. There is one complication the U.S. Food and Drug Administration has decided to focus on that is even more unimaginable: operating room fires.

In late 2011, the FDA announced it would be partnering with healthcare organizations on a program called Prevent Surgical Fires. It may sound like an unusual move for the FDA, but the agency has devoted more resources to safety and prevention over the past few years in a number of areas. The Safe Use Initiative, for example, came online in 2009 with the goal of eliminating medication errors.

The FDA estimates that 550 to 650 surgical fires occur each year. Compared to about 1.5 million preventable adverse drug events each year, fires are fairly rare. Still, such a fire can be catastrophic, if not lethal, for the victim.

For example, last November a young woman needed to have three cysts on her head removed. During surgery, the cauterizing tool ignited the oxygen from the patient's oxygen mask. The flash fire engulfed the woman's face and neck. A year ago, a surgeon's electronic scalpel sparked, igniting the oxygen supply and causing a minor explosion. The patient sustained severe burns to his neck and chest.

Like any fire, the surgical fire needs fuel, a source of ignition and an oxidizer. In the operating room, the fuel can be tracheal tubes, sponges or even surgical drapes. The ignition source is likely to be an instrument with a laser, a drill or a cauterizing device. Add in the super-oxygenated atmosphere of the operating room, and conditions are ripe.

The vast majority of burn victims, regardless of the source or location of the fire, survive their injuries. But recovery can take years and can mean additional surgeries and months of rehabilitation. Treatments are designed to mitigate the damage, but patients must live with the consequences: scars, disfigurement and, at times, chronic pain.

Source: Kentucky Post, "FDA focusing on patients catching fire in operating rooms," Aisling Swift, June 12, 2012