Surgical teams at Christiana Care Health System in Wilmington, Del., go through the same type of universal protocols that other hospitals employ by confirming the correct patient is on the table for the correct procedure at the right time. But there's one notable difference. A surgical fire risk assessment score is assigned to each case.

By linking the fire risk assessment to the universal protocol, the institution continuously raises staff awareness about the potential fire hazards present in all surgical procedures.

This culture shift was an outgrowth of internal soul-searching that came after two surgical fires occurred within eight months of each other at Christiana Care in 2003, says Kenneth L. Silverstein, M.D., chair of the department of anesthesiology and medical director of perioperative services.

Silverstein explained his institution's enhanced protocols during the Food and Drug Administration's October launch of a surgical fire-prevention initiative. The effort is aimed at raising awareness about the fire risks associated with surgical procedures performed in the oxygen-rich operating room environment while providing hospitals with the resources and training tools needed to reduce surgical fires. (For access to educational and training resources, including a free fire safety video developed by the Anesthesia Patient Safety Foundation, visit

Mark Bruley, the ECRI Institute's vice president of accident and forensic investigation, says surgical fires remain rare; only about 20 of the 550 to 650 fires reported annually seriously harm patients. But when serious fires do occur, the results can be devastating to patients and surgical teams.

A 35-year veteran of investigating surgical fires, Bruley believes a cultural change like the one that occurred at Christiana Care is needed in surgical suites across the country. Everyone on the surgical team should have authority to speak up about potential fire threats they observe, he says.

"This is a rare but real hazard that should be addressed through cultural change within the surgical team, the same as has been done with retained surgical instruments and wrong-site surgery," Bruley says.