Prevalence and root causes of operating room fires in the United States 2014-2024.

Abstract

Background: Operating room fires, though rare, pose serious risks to patient and operator safety. Among the known ignition sources, light-emitting surgical devices-including fiberoptic cables, headlamps, and light boxes-are increasingly recognized contributors. However, the true prevalence and underlying causes remain under-characterized in national surveillance data. This study hypothesized that operator error is a leading cause of light-source-related fires and sought to identify specific device types, procedural timing, and preventable risk factors involved in these adverse events.

Methods: Reports from the U.S. FDA's MAUDE database were analyzed for light source-related operating room fires from January 1, 2014, to January 1, 2024. Events were categorized by device type, procedural timing, root cause, and resultant injury.

Results: A total of 45 adverse events were analyzed. Most fires were associated with light sources (33.3%), light headlamps (31.1%), and fiberoptic cables (20%). Intraoperative fires comprised the majority (35.6%). Operator error accounted for 37.8% of cases, with common errors including device mishandling (35.2%) and failure to detect damage (17.6%). Only 13.3% required intra-procedural interventions; injuries included one patient burn and two operator injuries.

Conclusions: Most operating room fires involving light sources were linked to modifiable operator errors. These findings underscore the urgent need for preventive strategies-including mandatory training, regular equipment checks, and improved design standards-to reduce intraoperative fire risk and enhance surgical safety.