New Joint Commission Fire Safety Standard-Jan 2018

New Joint Commission Fire Safety Standard-Jan 2018

posted by Leslie Scott on Feb 13, 2018 10:52 am

The new JC fire safety standards reads as follows...

EP12. When flammable germicides or antiseptics are used during surgeries utilizing electrosurgery, cautery, or lasers, the following are required: 
- Nonflammable packaging
- Unit-dose applicators 
- Preoperative "time-out" prior to the initiation of any surgical procedure to verify the following: 
- Application site is dry prior to draping and use of surgical equipment 
- Pooling of solution has not occurred or has been corrected 
- Solution-soaked materials have been removed from the operating room prior to draping and use of surgical devices 
(For full text, refer to NFPA 99-2012: 15.13)

I would like to know how other facilities are managing the last bullet regarding removing solution soaked materials from the operating room. Do you have a two-person verification of the bag contents before they leave the room? a special receptacle for them? We have always been taught that everything stays in the room until the case is complete so it is a bit difficult to wrap our heads around. Thank you in advance for your feedback!

Re: New Joint Commission Fire Safety Standard-Jan 2018

posted by Patricia Cady on Feb 14, 2018 10:48 am

I was trying to find this under the Joint commision website and I cannot find it.  Did Joint Commission mention this in their last visit to your facilty?  Is the Joint commission following the NFPA standards?  Thank you in advance.

Re: New Joint Commission Fire Safety Standard-Jan 2018

posted by Mary Fearon on Feb 14, 2018 6:11 pm

AORN has reached out to the Joint commission to discuss the interpretive statements for the NFPA code  AORN believes this is causing difficulty in compliance with both the Joint Commission standards and the AORN Guidelines.  Removing the solution soaked materials  prior to draping could require more door opening, removal of counted items from the room or remove the circulating RN from the room at a critical time of the procedure.  AORN is recommending that the solution soaked materials be contained within the room away from the ignition source.  Please work with the Joint Commission to resolve any concerns about meeting this requirement and escalate your concerns to the central office if it cannot be resolved.

Re: New Joint Commission Fire Safety Standard-Jan 2018

posted by Carole Mayes on Feb 15, 2018 8:56 am

Good morning.
I am thinking the key is "soaked materials." How often are materials soaked? Just a thought.


Re: New Joint Commission Fire Safety Standard-Jan 2018

posted by Michael McKay on Feb 15, 2018 11:40 am

I agree, "soaked", is a frightening concept.   We have always been taught to avoid the  pooling of prep solutions, so I feel leaving material "soaked" with prep solution beneath the patient during surgery is wrong from the start.

We have enough trouble in our OR keeping the surgeon from starting before the prep has dried.
 Containing and eliminating prep "soaked" materials prior to starting a procedure is another delay that could be hard to swallow. 

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