General fire safety and operating room fire prevention protocol

Facility Safety

KEIT DAY HOSPITAL

General fire safety and operating room fire prevention protocol

Official Manual of Clinical, Care and Organizational Protocols

1. Document Control Information

2. Scope of Application

Applicable to all areas of the clinic, with a dedicated section addressing the specific fire risks associated with the operating room.

3. Responsibilities

• Safety and Facility Manager: development and maintenance of the fire safety plan, staff training and emergency drills.
• Operating room personnel: management of the fire triad and compliance with specific intraoperative fire-prevention measures.
• All personnel: knowledge of evacuation routes, alarm systems and evacuation procedures.

4. Operating Procedure

• Periodically inspect fire extinguishers, alarm systems, emergency exits, fire compartments and safety signage.
• Train personnel in fire prevention, initial emergency response and evacuation procedures.
• In the operating room, assess the risk of fire for every procedure based on the presence of oxidizers, ignition sources and combustible materials.
• Ensure that antiseptic solutions are completely dry and carefully manage oxygen, electrosurgical units, cables and surgical drapes.
• In the event of an incipient fire, discontinue the ignition source, stop the oxidizer supply when appropriate, remove the affected material and activate the emergency response plan.
• Document the event and review the factors that contributed to its occurrence.

5. KEIT Operational Standards

• The operating room protocol includes explicit attention to the fire triad and coordination among the surgeon, anesthesiologist and scrub nurse.
• Fire drills form part of the facility’s organizational safety system.

6. Records and Documentation

• Fire safety inspection register.
• Evacuation drill records.
• Fire or incipient fire incident report.

7. Review and Updates

Periodic updates in collaboration with the Safety Manager and following every drill or identified non-conformity.

8. Related Attachments and Forms

• Operational checklists, recording forms, audit sheets and maintenance registers applicable to this protocol.
• Any department-specific or equipment-specific technical attachments are referenced in the relevant local operating instructions.

9. Final Approval