Case Study with Risk Management Strategies
Presented by NSO and CNA
Case Study: Alleged failure to follow fire prevention protocols resulted in an operating room (OR) fire.
Medical malpractice claims may be asserted against any healthcare provider, including CRNAs. This case study involves an insured CRNA with approximately 15 years of experience who was practicing in an ambulatory surgery center (ASC). The incident occurred in a state that permits independent practice for CRNAs.
Summary
A 48-year-old woman presented to the ASC for a bilateral blepharoplasty to correct ptosis with visual obstruction. Her medical history included well-controlled hypertension and anxiety. Other than the physical visual obstruction caused by the ptosis, she had normal vision and did not wear corrective lenses. The CRNA conducted the preoperative anesthesia physical assessment and informed consent discussion. The assessment revealed an ASA Physical Status of Class 1 with a Mallampati Class 1 airway, mouth opening > 4cm, thyromental distance >7.5 cm, and good neck mobility with normal flexion and extension. The patient’s vital signs were stable, with an oxygen saturation of 98 percent on room air. Based on the patient’s medical history, vital signs, and airway assessment, the CRNA determined that monitored anesthesia care (MAC) using propofol and midazolam was appropriate, with supplemental oxygen administered via a non-rebreather mask.
The CRNA informed the patient that monitored anesthesia care (MAC) would be used and explained that it would involve intravenous sedation while maintaining spontaneous ventilation, with continuous monitoring throughout the procedure. The CRNA discussed the risks of MAC anesthesia, including respiratory depression, hypoxia, hemodynamic changes, potential need for airway intervention or conversion to general anesthesia as well as medication adverse reactions. Although the CRNA initialed the anesthesia consent form, he inadvertently forgot to obtain the patient’s signature.
The patient was transferred to the operative suite and, during the surgical site preparation, the scrub nurse applied an alcohol-based prep solution onto the patient’s face. She promptly recognized that the solution was contraindicated for facial procedures and immediately initiated corrective actions, including thorough cleansing of the area and allowing approximately four minutes for drying prior to the application of the appropriate povidone-iodine prep. The surgeon and CRNA were notified and confirmed that the alcohol solution had not saturated the patient’s hair or underlying materials. A surgical time-out was completed, during which an elevated fire risk score of three was discussed, indicating that all three components of the fire triad were present and that enhanced fire prevention precautions were warranted. The surgeon acknowledged the elevated fire risk and confirmed implementation of targeted mitigation strategies, including requesting notification by anesthesia of any increase in oxygen administration, configuring drapes to avoid oxygen accumulation, and announcing activation of electrocautery when in proximity to the oxidizer-enriched surgical field.
The surgery was performed without complication; however, as the surgeon began closing the incision, he noted a small area of bleeding and informed the CRNA that he would be using the electrocautery again briefly. In response, the CRNA discontinued the oxygen flow for approximately two to three minutes and suctioned beneath the surgical drapes to reduce any residual oxygen in the field. The surgeon then completed the electrocautery, and, within seconds, a fire ignited beneath the drapes covering the patient’s neck and chest and a portion of her face. The surgeon immediately removed the drapes, irrigated the patient’s face and neck with sterile saline, and applied topical silver sulfadiazine to the affected areas. Drapes and surgical materials that had fallen to the floor were promptly extinguished by the circulating nurse. The patient reported that her vision was unaffected, and there was no respiratory compromise. The non-rebreather mask was removed, and the CRNA intubated the patient as a precautionary measure to secure the airway and mitigate the risk of airway edema.
The patient sustained facial and neck burns, along with singeing of the eyelashes, eyebrows, and hair. She was monitored for approximately one hour and was then transferred to a tertiary care facility for further burn management where she was diagnosed with deep partial-thickness burns to the temporal regions and superficial burns involving multiple areas of the face and neck. The patient was extubated on hospital day two after an evaluation confirmed that there was no evidence of inhalation injury. She was discharged on hospital day four in stable condition with corticosteroids and analgesics for ongoing pain management.
Risk Management Comments
The patient was left with significant facial scarring, for which future plastic surgery was planned. Approximately six months after the incident, the patient filed a lawsuit collectively against the hospital, surgeon, scrub nurse and CRNA. The plaintiff asserted that the management of anesthesia was inappropriate and the surgical team failed to adhere to standard OR fire prevention protocols. The plaintiff asserted that the choice of oxygen delivery by the CRNA was inappropriate, i.e. the CRNA’s decision to use an open oxygen source via a non-rebreather mask for an ophthalmic procedure was a departure from the standard of care.
The plaintiff asserted that she sustained the following injuries as a result of the OR fire:
- Burns to the face, scalp, neck, and clavicular regions.
- Bilateral loss of tear film homeostasis resulting in the development of keratoconjunctivitis sicca (KCS) and visual disturbances.
- Chronic facial numbness, pain, pruritus, and disfigurement.
- Altered phonation.
- Exacerbation of a pre-existing anxiety disorder, including development of a pyrophobia.
The plaintiff claimed that the improper anesthesia care resulted in permanent scarring requiring plastic surgery, the need for therapeutic eyeglasses, as well as ongoing speech therapy and psychological counseling.
The plaintiff’s CRNA expert’s theory of liability centered on lack of appreciation for the high fire risk present in this case. He testified that all elements of the “fire triad” were present, identifying electrocautery as the ignition source, the chlorhexidine-alcohol skin preparation and/or the drape as the fuel, and the administration of high-flow oxygen by anesthesia as the oxidizer. The expert acknowledged the CRNA’s testimony that oxygen delivery was discontinued, and suction was applied beneath the drapes when electrocautery was anticipated; however, the expert opined that these measures do not reliably eliminate elevated oxygen concentrations, particularly in enclosed spaces such as beneath surgical drapes or within a face mask. The expert opined that the incident was preventable and asserted that the fire would not have occurred had appropriate OR fire prevention protocols been consistently followed.
A significant defense challenge in this case was finger pointing among the co-defendants. The CRNA attributed the cause of the fire to improper skin preparation by the scrub nurse. He testified that the oxygen had been discontinued at least two to three minutes prior to the use of electrocautery and that no oxygen was actively being delivered at the time. The CRNA stated that gas monitoring was performed continuously; however, these levels were not documented as facility policy did not require formal documentation of these readings. The CRNA justified his decision to use a high concentration of oxygen via face mask, as opposed to a nasal cannula, citing that the patient’s preoperative anxiety as the clinical rationale and testified that, under the circumstances, the use of a non-rebreather mask was reasonable.
The scrub nurse admitted to erroneously selecting an alcohol-based skin preparation but maintained that only a limited amount had been applied and that the area was promptly and thoroughly cleansed and allowed to dry once the error was recognized. The surgeon testified that the fire was more likely attributable to the use of high-concentration oxygen that may have accumulated beneath the drapes, rather than to the application of the alcohol-based preparation.
The defense CRNA expert was unable to support the use of high-flow oxygen delivered via a non-rebreather mask, noting that the patient had no history of pulmonary disease. The expert opined that while the use of a high-flow non-rebreather mask during ophthalmic procedures may be clinically appropriate in select circumstances—such as in patients with increased oxygen requirements or intraoperative hypoxia—its routine use during procedures involving the face warrants careful consideration. Specifically, the administration of high concentrations of oxygen in proximity to an ignition source, such as electrocautery, may significantly increase the risk of an operating room fire, and he therefore opined that alternative oxygen delivery methods would have been more prudent.
In addition, the expert stated that although the CRNA discontinued the oxygen source upon learning that the surgeon planned to resume use of electrocautery, the non-rebreather mask remained in place on the patient’s face. The expert noted that oxygen concentration cannot be measured in an open delivery system such as a non-rebreather mask and that best practice would have been to remove the mask entirely. While some residual oxygen would likely remain, removing the device would further reduce the amount of oxygen present in the surgical field. Alternatively, the expert indicated that placement of a supraglottic airway device could have contained the oxygen source during cautery use.
The defense expert explained that oxygen concentration at the patient level cannot be measured once it is discontinued in an open system such as a non-rebreather mask. Because oxygen delivery using a non-rebreather mask is variable and dependent on flow rate, mask fit (lack of a sealed circuit) and the patient’s respiratory pattern, the oxygen concentration cannot be accurately measured and there is no reliable way to quantify how much oxygen lingers around the face or under the drapes once the flow is stopped. This limitation may account for the CRNA’s lack of documentation during that period.
Resolution:
In addition to the above-mentioned defense challenges, photographic evidence depicting the patient’s facial injuries following the fire was anticipated to create a significant emotional impact on the jury. Defense counsel believed that the plaintiff’s expert’s criticisms could be compelling to a jury and that it would be plausible for jurors to conclude that fire prevention protocols were not consistently followed. The defense team believed that there was a limited chance for a defense jury verdict. The parties agreed to mediation, and the claim was settled on behalf of the CRNA.
Total Incurred: More than $500,000.
(Monetary amounts represent the payments made only on behalf of the CRNA)
Risk Management Recommendations
- Adhere to current guidelines from professional industry associations such as the Anesthesia Patient Safety Foundation , the American College of Surgeons and the AANA including but not limited to the following:
- Assess fire risk during the pre-procedure time-out to identify the presence of elements in the fire triad.
- Consider using an invasive device such as a supraglottic airway or endotracheal tube if cautery is being used for facial surgery. Face masks and non-rebreathers require high flow oxygen and the concentration of oxygen can only be accurately manipulated with invasive devices.
- Maintain open communication with the surgical team when an ignition source i.e. electrocautery or laser is going to be used in the vicinity of an oxygen-enriched area.
- Moisten pads with saline to reduce flammability.
- Configure drapes to limit the accumulation of oxygen.
- Conduct thorough informed consent discussions prior to treatment, including a clear explanation of the procedure, risks, benefits, and alternatives. Document the discussion in the healthcare information record, including any patient questions asked and the responses provided.
- Document all pertinent patient information in the healthcare information record in an objective, concise manner. Maintaining consistent, comprehensive, and timely documentation of services is the best defense in the event of a professional liability claim.
- Seek opportunities for continuing education related to prevention of OR fires and participate in simulations involving emergency management should a fire occur.
Disclaimer
The information, examples and suggestions presented in this material have been developed from sources believed to be reliable as of the date they are cited, but they should not be construed as legal or other professional advice. CNA, Aon, Affinity Insurance Services, Inc., NSO, or HPSO accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All products and services may not be available in all states and may be subject to change without notice. Certain coverages may be provided by a surplus lines insurer. Surplus lines insurers do not generally participate in state guaranty funds, and insureds are therefore not protected by such funds. The claims examples are hypothetical situations based on actual matters. Settlement amounts are approximations. Certain facts and identifying characteristics were changed to protect confidentiality and privacy. Any references to non-CNA, non-Aon, AIS, NSO, and HPSO websites are provided solely for convenience, and CNA, Aon, AIS, NSO and HPSO disclaim any responsibility with respect to such websites. “CNA” is a registered trademark of CNA Financial Corporation. Certain CNA Financial Corporation subsidiaries use the “CNA” trademark in connection with insurance underwriting and claims activities. This material is not for further distribution without the express consent of CNA. Copyright © 2026 CNA. All rights reserved.
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