title: Alcohol skin preparation causes surgical fires.
abstract: BACKGROUND
  Surgical fires are a rare but serious preventable safety risk in modern hospitals. Data from the US show that up to 650 surgical fires occur each year, with up to 5% causing death or serious harm. This study used the National Reporting and Learning Service (NRLS)  database at the National Patient Safety Agency to explore whether spirit-based surgical skin preparation fluid contributes to the cause of surgical fires.
  
  
  METHODS
  The NRLS database was interrogated for all incidents of surgical fires reported between 1 March 2004 and 1 March 2011.  Each report was scrutinised manually to discover the cause of the fire.
  
  
  RESULTS
  Thirteen surgical fires were reported during the study period. Of these, 11 were found to be directly related to spirit-based surgical skin preparation or preparation soaked swabs and drapes.
  
  
  CONCLUSIONS
  Despite manufacturer's instructions and warnings, surgical fires continue to occur. Guidance published in the UK and US states that spirit-based skin preparation solutions should continue to be used but sets out some precautions. It may be that fire risk should be included in pre-surgical  World Health Organization checklists or in the surgical training curriculum. Surgical staff should be aware of the risk that spirit-based skin preparation fluids pose and should take action to minimise the chance of fire occurring.
authors.affiliation: National Patient Safety Agency, London, UK. brettrocos@gmail.com
authors.forename: B
authors.initials: B
authors.lastname: Rocos
authors.forename: L J
authors.initials: LJ
authors.lastname: Donaldson
mesh_terms: D000438:Alcohols; D000891:Anti-Infective Agents, Local; D005390:Fires / Q000517:prevention & control*; D006801:Humans; D009873:Operating Rooms; D061214:Patient Safety; D011300:Preoperative Care / Q000379:methods; D012307:Risk Factors; D017751:Safety Management; D013514:Surgical Procedures, Operative
chemical_list: D000438:Alcohols; D000891:Anti-Infective Agents, Local