SURGERY/OR COUNTCustom LAYOUT EXAMPLES

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ITEM

Patient Name ProcedureID #INITIALCOUNT ADDITIONAL ITEMS

Scoring:3 or higher = High Risk = Initiate Protocol2 = Low risk with potential to convert to high risk1 = Low risk

High Risk = Safety Protocol InitiatedWrite “Fire Risk High” on dry erase board - Fire extinguisher available and easily accessible

Towels

Lap Sponges

Raytecs

Blades

Needles

Kittners

Free Needles

Hypos

Bovie Tips

Bovie Scratchers

Disp. Tonsil Suction

Disp. Poole Suction

Vessel Loops Mini

Vessel Loops Maxi

Rubber Shods

Penrose Drains

Drain Trocars

Safety Pins

Umbilical Tapes

Syringes

Suture Reels

Hemoclip Loads

Auto Suture Reloads

Specimen / Medicine Cups / Lids

Skin Markers

Total Score

Circle Appropriate Option YES NO

Is an alcohol-based prep agent or other volatile chemical being used preoperatively?

Is the procedure being performed above the xiphoid process?

Is open oxygen or nitrous oxide being administered (delivery via nasal cannula, face mask, or ETT)?

Is an ESU (Electrical Surgical Unit), Laser, or Fiber-Optic Light Cord being used?

11111

00000Are there other possible contributors (e.g. bone cement, defibrillator, drills, saws, burrs)?

FIRE ASSESSMENT PROTOCOL

MEMORIALMUNICIPAL HOSPITAL

PATIENT NAME AGE

SURGEON PROCEDURE ALLERGIES

COUNTS

WEIGHT

SPECIAL CONSIDERATIONS

GENERAL SURGERY

LAPS

RAYTEX

HYPOS

BLADES

NEEDLES

BOVIE TIPS

LIGACLIPS

REELS

TOWELS

DRAINS

SCISSOR TIPS

FOG PADS

ANTIBIOTICS

X-RAYS DISPLAYED

MEDICATIONS ON FIELD

CIRCULATOR HAND-OFF

FOLEY / DRAINS

ANESTHESIA

BOVIE PAD

SPECIMENS ON / OFF FIELD

FAMILY MEMBER

COUNTS

SITE MARKED BROSELOW SCALE FIRE RISK SCORE

MEMORIAL SURGERY CENTER

PT Name

Procedure(s)

Allergies

Fire Risk Score

Blood Type

PRBC

FFP

PLT

Cryo

Ice Exp

MRN

Age

Latex Y / N

Date DOB Contacts/Phone/ //Count

Family Notification

Special Items/Comments

Laps

Raytec

CV Needles

Single Needles

Free Needles

Blades

Bovie Tips

Valve Needles

Sternal Wires

Pacing Wires

Retractor Tape

Peanuts

Suture Boots

Vessel Loops

U-Tape

Bulldogs

Hypos

Bumps

Other

UNIVERSITY HOSPITAL

2015

Patient

Birthdate

Allergies

Surgeon

Procedure

Vendor

Students

Tourniquet #

Bovie #

Bair Hugger #

Time in Room

Start Time

Family Member

Last Notified

FIRE RISK ASSESSMENT

Y

1

1 0

1 0

1 0

N

0

0 1

Scoring:3 or more = High Risk2 = Medium Risk (potential to convert to High Risk)1 = Low Risk0 = No Risk

Instructions for use of fire risk assessment tool:

1. Answer the questions and assign a number which correlates to the yes or no

2. Total the columns

3. During time out announce the first risk

Circle Appropriate Option

LAPSRAYTECBLADESESU TIPSHYPONEEDLES

Alcohol based prepsolution had sufficient time to dry

Surgical site or incision above the xiphoid

Open oxygen source(Patient receiving supplemental oxygen via any face mask or nasal cannula)

Ignition source (ESU, Laser, light cable)

Are there other possible contributors? (e.g. defibrillator, drills, saws, burrs)

Total Score

MEMORIAL SURGERY CENTER

FIRE RISK ASSESMENTSurgical site above xyphoid?

Open oxygen source?Available ignition source?

If All 3 Are Yes, Initiate High Risk Protocol.

SpongesTotalSuturesLaps

Raytecs

Blades

Equipment Numbers

Notes

Bovie #1

Bovie #2

Slush / Warmer / Both

Bair Hugger

Video Tower

Camera

Insufflator

Light Source

Harmonic

Ligasure

Argon

SCD

Others

Scratch Pad

D. Fred

Grey Clips

Green Towels

Angio

Cook NDL

Dilators

Bovie Tip

Boots

F. Inserts

Vessel Loops

U-Tapes

Hypos

Clips

KD

Penrose

Thoracic Count

Mayo NDLS

0 Vicryl

2/0 Vicryl

3/0 Vicryl

4/0 Vicryl

1 PDS

2/0 PDS

3/0 PDS

2/0 Prolene

(DA) 3/0 Prolene

(DA) 4/0 Prolene

2/0 Monocryl

4/0 Monocryl

3/0 Chomic

2/0 Ethilon

3/0 Ethilon

2 Ethilon

0 Silk

2/0 Silk

3/0 Silk

(8P) 3/0 Silk

(8P) 4/0 Silk

(15)(10) (11)

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