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Flammable Antiseptics

You are here: Home / Survey Readiness / Flammable Antiseptics
March 3, 2021
Fire,Alarm,And,Firefighting,Automation,Control,Hospital,System,Concept.

If you use flammable antiseptics before procedures and surgeries you need to take these steps to prevent problems including surgical fires.

There is some important information that comes from the February Consistent Interpretation column. This is a must read for all quality, operating room, and procedural setting staff who use any flammable antiseptics before procedures and surgeries as improper use of any of these agents can result in surgical fire.

Flammable Antiseptics

The element of performance that you are going to want to pay attention to is EC.02.03.01, EP 12.

What is EC.02.03.01, EP12?

According to The Joint Commission’s 2021 Hospital Accreditation manual, it is “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”

Even while the 2019 noncompliance rate was only 2.34%, the proper use of these agents is difficult to observe therefore may be missed, causing a major error.

It’s A Different Time-out!

Please pay attention to the use of the term “time-out.”  This is NOT what you think it is and is not the presurgical time-out we are all familiar with!

This “time-out” requires three verifications, as noted in the EP text above.  What you will also want to pay attention to is #3.  The term “removed” comes straight from the current NFPA language, however, the phrase “removed from the operating room” has been interpreted in this case to simply mean removed from the proximity to the patient.

Unfortunately, there is no current FAQ or note within the EP explaining this more flexible interpretation.  We highly recommend sharing this column and the full text of NFPA 99-2012: 15.13 with operating room staff.
As previously stated, proper use of these agents is difficult to observe, so contact us today so we can be your extra eyes to help your organization provide the best patient safety possible.

Category: Survey Readiness
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