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)
MemorialHospital
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