Fire in operating room: The adverse “never” event. Case report, mini-review and medico-legal considerations

The patient's security and safety represent a topic of great importance for public health that led several healthcare organizations in many Countries to share documents to promote risk management and preventing adverse events. Surgical Fire (SF) is an infrequent adverse event generally occurring in the operating room (OR) and consisting of a fire that occurs in, on, or around a patient undergoing a medical or surgical procedure. Here a medico-legal case involving a 65-year-old woman reporting burns to the neck due to an SF during a thyroidectomy was described. A literature review was performed using Pubmed and Scopus databases, focusing on epidemiology, causes, prevention activities associated with the SF, and the related best practices recommendations. The medico-legal analysis of the case led to admit the professional liability because the suggested time (3 min) to use the electrocautery after CHG application was not respected. The case analysis and the literature review suggest the importance of implementing National and Local procedures to promote the management of SF risk. Finally, it is necessary to highlight the role of incident reporting and root causes analysis in understanding the cause of the adverse events and thus enforce their prevention.