[Facility Name]
Perioperative RN Performance Evaluation Tool
Fire Prevention and Management
Perioperative RN:
Title:
Practice area:
Date:
Competency Statement: The perioperative RN has met the requirements for competency validation in perioperative fire prevention and management.
Source: Recommended practices for a safe environment of care. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:217-242.
Outcome Statement: Patient is free from signs and symptoms of injury related to thermal sources.
Source: Petersen C, ed. Thermal injury. In: Perioperative Nursing Data Set. 3rd ed. Denver, CO: AORN, Inc; 2011:139-145.
Validation Method
[Select appropriate code from legend at bottom of page]
DEM/
Performance Criteria
DO/DA
S/SBT/
KAT
CS
RWM/
V
P&P
O
Not Met
(Explain why)
1. Explains the elements of the fire triangle as they relate to the
perioperative environment.
2. Communicates the fire risk assessment and identifies
a. fuels that are present,
b. ignition sources that are present,
c. the potential presence of an oxygen-enriched environment,
d. the specific type of fire extinguisher that is required for the fuel or
electrical current, and
e. any additional preventive measures that are required as determined
by the location of the fire and fuel sources.
3. Documents the fire risk assessment in the perioperative record.
4. Manages fuel sources to prevent contact with ignition sources by
a. determining flammable or combustible rating of skin antiseptic
agent by reviewing applicable material safety data sheet (MSDS) or
safety data sheet (SDS),
b. preventing the pooling of prep solutions,
c. using reusable or disposable sterile towels to absorb drips and
excess solution during application,
d. removing materials that are saturated with the skin antiseptic agent
DEM/DO/DA
S/SBT/CS
RWM/P&P
=
=
=
Demonstration/Direct Observation/Documentation Audit
Skills Laboratory/Scenario-based Training/Controlled Simulation
Review of Written or Visual Materials/Policy/Procedure Review (Specify P&P #s _________________)
KAT =
V
=
O
=
Knowledge Assessment Test
Verbalization
Other: ____________________________________________________
This tool is excerpted from Perioperative Job Descriptions and Competency Evaluation Tools CD-ROM. Copyright © 2012 AORN, Inc. All rights reserved. Used with permission.
Page 1 of 5
[Facility Name]
Perioperative RN Performance Evaluation Tool
Fire Prevention and Management
Validation Method
[Select appropriate code from legend at bottom of page]
DEM/
Performance Criteria
DO/DA
S/SBT/
KAT
CS/
RWM/
V
P&P
O
Not Met
(Explain why)
before draping the patient,
e. providing adequate time to allow flammable skin antiseptic agent to
dry completely and allowing any fumes to dissipate before applying
surgical drapes or using a potential ignition source, and
f. verifying that a water-soluble gel is used to cover the patient’s
facial hair and that a water-based eye lubricant is used during
procedures involving the head or neck.
5. Manages ignition sources by verifying that
a. ignition sources are used according to validated manufacturers’
written instructions for use and AORN recommended practices,
b. saline is used to cool devices that create heat during use (eg, drills,
burrs, saws blades), and
c. defibrillator paddles and pads of the appropriate size for the patient
are available and are applied according to validated manufacturer’
instructions and using only manufacturer-recommended lubricants.
6. Manages oxidizers by verifying that
a. the anesthesia circuit is free of leaks,
b. the anesthetic gas is evacuated using a metal suction cannula before
ignition source is used in or near an oxygen-enriched environment,
c. the lowest possible concentration of oxygen is used to provide
adequate oxygen saturation for patients requiring supplemental
oxygen,
d. a laryngeal mask airway or an endotracheal tube is used when the
patient requires supplementary oxygen greater than 30% (unless
using the tube is contraindicated by the procedure),
e. drapes are placed over the patient’s head in a manner that allows
the oxygen to flow freely and prevent accumulation under the
drapes,
DEM/DO/DA
S/SBT/CS
RWM/P&P
=
=
=
Demonstration/Direct Observation/Documentation Audit
Skills Laboratory/Scenario-based Training/Controlled Simulation
Review of Written or Visual Materials/Policy/Procedure Review (Specify P&P #s _________________)
KAT =
V
=
O
=
Knowledge Assessment Test
Verbalization
Other: ____________________________________________________
This tool is excerpted from Perioperative Job Descriptions and Competency Evaluation Tools CD-ROM. Copyright © 2012 AORN, Inc. All rights reserved. Used with permission.
Page 2 of 5
[Facility Name]
Perioperative RN Performance Evaluation Tool
Fire Prevention and Management
Validation Method
[Select appropriate code from legend at bottom of page]
DEM/
Performance Criteria
DO/DA
S/SBT/
KAT
CS/
RWM/
V
P&P
O
Not Met
(Explain why)
f.
a second delivery system is used to administers 5 L/minute to 10
L/minute of medical air when supplemental oxygen is administered
under the drapes,
g. additional precautions are taken when surgical procedures are
performed on anatomical structures (eg, bowel, trachea) that
present special fire hazards (eg, using a scalpel rather than an
electrosurgical active electrode to create the incision), and
h. wet radiopaque sponges are placed in the back of the throat and that
tinted solutions are used to inflate the endotracheal tube during
procedures involving the airway.
7. Follows communication, suppression, and evacuation procedures in the
event of a fire by
a. alerting perioperative team members to the presence of the fire,
b. using water or normal saline to extinguish the fire safely,
c. not using a fire extinguisher as the first line of defense in a fire,
d. removing the fuel source from the patient,
e. extinguishing the fire,
f. identifying established evacuation routes, and
g. evacuating the OR or procedure room according to the facility fire
plan if unable to extinguish the fire.
8. Follows emergency procedures in the event of a small fire on the
patient by
a. smothering or drowning the fire and
b. removing burning material from the patient.
9. Follows emergency procedures in the event of a large fire on the patient
by
a. stopping the flow of breathing gases to the patient;
b. removing burning material from the patient;
DEM/DO/DA
S/SBT/CS
RWM/P&P
=
=
=
Demonstration/Direct Observation/Documentation Audit
Skills Laboratory/Scenario-based Training/Controlled Simulation
Review of Written or Visual Materials/Policy/Procedure Review (Specify P&P #s _________________)
KAT =
V
=
O
=
Knowledge Assessment Test
Verbalization
Other: ____________________________________________________
This tool is excerpted from Perioperative Job Descriptions and Competency Evaluation Tools CD-ROM. Copyright © 2012 AORN, Inc. All rights reserved. Used with permission.
Page 3 of 5
[Facility Name]
Perioperative RN Performance Evaluation Tool
Fire Prevention and Management
Validation Method
[Select appropriate code from legend at bottom of page]
DEM/
Performance Criteria
10.
11.
12.
13.
14.
15.
DO/DA
S/SBT/
KAT
CS/
RWM/
V
P&P
O
Not Met
(Explain why)
c. smothering or drowning the fire;
d. extinguishing any burning material with the appropriate fire
extinguisher or water, if appropriate; and
e. assessing the surgical field for a secondary fire of the underlying
drapes or towels.
Assists the anesthesia professional in the event of an airway or ET tube
fire
a. by disconnecting and removing the breathing circuit,
b. by turning off the flow of oxygen,
c. with removing the ET tube and any segments of the burned tube
that remain in the airway,
d. by pouring water or saline into the airway if instructed,
e. with re-establishing the airway,
f. with resuming ventilation using room or medical air or switching to
100% oxygen as appropriate for the patient, and
g. with examining the airway.
Reports the fire and saves all items involved in the fire after the fire is
extinguished.
Identifies the equipment that emits unanticipated smoke and
a. disconnects equipment (whether or not in use) from the electrical
current source,
b. moves equipment and all accessories in use to a safe area, or
c. evacuates the OR if equipment cannot be removed safely.
Describes the fire alarm activation procedure, including
a. the internal alarm system and
b. the external alarm system.
Identifies locations of pull station alarms.
Demonstrates pull station activation.
DEM/DO/DA
S/SBT/CS
RWM/P&P
=
=
=
Demonstration/Direct Observation/Documentation Audit
Skills Laboratory/Scenario-based Training/Controlled Simulation
Review of Written or Visual Materials/Policy/Procedure Review (Specify P&P #s _________________)
KAT =
V
=
O
=
Knowledge Assessment Test
Verbalization
Other: ____________________________________________________
This tool is excerpted from Perioperative Job Descriptions and Competency Evaluation Tools CD-ROM. Copyright © 2012 AORN, Inc. All rights reserved. Used with permission.
Page 4 of 5
[Facility Name]
Perioperative RN Performance Evaluation Tool
Fire Prevention and Management
Validation Method
[Select appropriate code from legend at bottom of page]
DEM/
Performance Criteria
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
DO/DA
S/SBT/
KAT
CS/
RWM/
V
P&P
O
Not Met
(Explain why)
Explains correct extinguisher selection.
Identifies the location of fire extinguishers in perioperative areas.
Demonstrates the PASS technique for using a fire extinguisher.
Describes RACE evacuation technique.
Identifies the closest safe location as the evacuation destination where
patient care can be continued.
Explains vertical and horizontal evacuation plans.
Locates fire doors.
Locates the smoke compartment.
Identifies medical gas control valves and describes
a. the areas they control and
b. the procedure for shutting down medical gases in the event of a fire.
Identifies the electrical panel location and describes the procedure for
turning off the electricity.
Does not store equipment (eg, case carts, stretchers, supply carts,
patient beds) in locations that block access to pull alarms, medical gas
control valves, or electrical panels.
Completes assigned educational and competency validation activities
related to fire safety.
DEM/DO/DA
S/SBT/CS
RWM/P&P
=
=
=
Demonstration/Direct Observation/Documentation Audit
Skills Laboratory/Scenario-based Training/Controlled Simulation
Review of Written or Visual Materials/Policy/Procedure Review (Specify P&P #s _________________)
KAT =
V
=
O
=
Knowledge Assessment Test
Verbalization
Other: ____________________________________________________
This tool is excerpted from Perioperative Job Descriptions and Competency Evaluation Tools CD-ROM. Copyright © 2012 AORN, Inc. All rights reserved. Used with permission.
Page 5 of 5