Cause of Device-Related Incident
External factors; Support system failures; User errors

Clinical Specialty or Hospital Department
CCU / ICU / NICU; Clinical/Biomedical Engineering; Nursing; Pulmonary / Respiratory Therapy

Device Factors
*Not stated

Document Type
Hazard Reports

External Factors
Medical gas and vacuum supplies

Mechanism of Injury or Death

Support System Failures
Failure to train and / or credential

Tampering and/or Sabotage
*Not stated

User Errors
Incorrect clinical use

Medical Gas and Vacuum Systems [18-046]

Responding to Fires in Areas of Oxygen Use

Hazard [Health Devices Jul 1994;23(7):309-10]


A fire started in the hospital room of a patient using oxygen, quickly rupturing the oxygen hoses attached to the piped oxygen wall outlets. The free-flowing oxygen then intensified the fire, which rapidly involved most of the flammable objects in the room. Copious amounts of smoke were forced out into the hall and throughout the patient floor, necessitating the evacuation of many patients. When the firefighters arrived, they shut off the oxygen to the room, which reduced the intensity of the fire and enabled them to extinguish it.


At least 10 hospital fires are reported each year. Many of these involve oxygen enrichment from supplemental oxygen sources and result in patient injury or, occasionally, death. Reducing the amount of oxygen reaching the fire directly affects the fire's severity, the damage it causes, and the hazards it poses to patients and staff.

Fire requires oxygen to burn. Fires occurring in normal ambient atmosphere—21% oxygen concentration—can be severe. However, fires occurring in oxygen-enriched atmospheres (OEAs)—those above 23.5% oxygen concentration—are larger, more intense, faster burning, and harder to extinguish; many materials that do not burn in room air can burn in an OEA. Regardless of the oxygen concentration, any fire can be slowed, lessened, or extinguished by removing oxygen from the area.

In hospitals, fire-fighting training programs stress closing windows and shutting doors to exclude oxygen from a burning room. However, when respiratory therapy equipment is in use, the only practical means of stopping the flow of piped oxygen, nitrous oxide, or medical compressed air (all of which enable a fire to continue to burn) into a patient room is by closing the pipeline zone valves.

Because zone valves typically control gas flow to several rooms, closing a valve may affect patients in more than one room, although residual pressure in the pipeline allows a short time before gas flow stops completely. Each zone valve must be labeled with the area it controls (e.g., "Oxygen Valve: Controls Rooms 901 through 906"). If a fire occurs in a room in which oxygen, nitrous oxide, or medical compressed air is in use, the zone valves controlling that room must be closed, and affected patients requiring respiratory support must be immediately assisted. Failure to close the zone valves risks intensifying and spreading the fire and smoke, placing more lives at risk.

According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), every hospital must have a plan for dealing with fire emergencies. This plan must account for the various hazardous actions, such as closing zone valves, that have to be risked to deal with a fire. The plan should be taught to all hospital staff, with periodic drills to reinforce the training.

The core of a fire plan involves the following steps, abbreviated by the acronym RACE:

  • Rescue patients in the immediate area of the fire. The person discovering the fire should perform the rescue if possible.
  • Alert other personnel to the fire so that they can assist. The discoverer should also let others know of a fire by yelling "Fire in room 119!" while rescuing the occupants. Other personnel hearing the alert should relay the information to the facility switchboard or other alarm system.
  • Contain the fire. Shut the door after rescuing the occupants to slow the spread of smoke and flame. Close fire doors. If oxygen and/or medical compressed air is in use in the room, shut off the zone valve controlling those gases to that room, and immediately assist all affected patients.
  • Evacuate other patients and personnel in the areas around the fire. Facility personnel trained in fire emergency procedures should respond to the initial alarm to assist in evacuating patients to safe areas.

Depending on the facility's layout and staffing, certain RACE tasks (e.g., alerting the switchboard, shutting fire doors, closing zone valves) should be preassigned. Amid the chaos of a fire, such tasks are not easy to remember or carry out. Training and drilling can help hospital personnel learn and remember these emergency duties. JCAHO requires appropriate education, training, and quarterly drilling for all personnel in all elements of the fire safety plan (see PL.2.3.2, Accreditation Manual for Hospitals, JCAHO, 1994).

Each facility should develop a customized plan that includes prepositioning emergency supplies to support and transport patients during evacuation. Regulators, manual resuscitators, masks, hoses, carts, oxygen cylinders, blankets, and other necessary equipment should be readily available near patient areas. These supplies should be regularly inspected and maintained in readiness. Hospital personnel should also be trained in the use of this equipment.


  • Develop and maintain a plan to deal with fire emergencies. This plan should include operation of medical gas and vacuum system zone valves.
  • Train and drill all hospital staff in execution of this plan.
  • Establish and maintain emergency supplies for patient evacuation. These supplies should enable respiratory support of patients during transport from the affected area to a safe haven.
  • Ensure that all medical gas and vacuum system zone valves are functional, correctly labeled, and included in a routine inspection program. (Refer to the Inspection and Preventive Maintenance [IPM] Procedure, "Medical Gas and Vacuum Systems," in Health Devices 23[1-2], Jan-Feb 1994.)

For Further Information

A detailed discussion of the type of incident described in this report can be found in Summary Fire Investigation Report—Hospital Fire, Brooklyn New York, September 1, 1993, which is available from the Department Secretary for Fire Investigation, National Fire Protection Association (NFPA), 1 Batterymarch Park, Quincy MA 02269-9101.

For additional information on planning for fire emergencies, see Section C-8.3, Suggested Fire Response, Respiratory Therapy, in Standard for Health Care Facilities (ANSI/NFPA 99, An American National Standard), and "The Patient Is on Fire!" in Health Devices 21(1), Jan 1992.


Medical Gas and Vacuum Systems [18-046]

Cause of Device-Related Incident

User error: Incorrect clinical use

External factor: Medical gas and vacuum supplies

Support system failure: Failure to train and/or credential

Mechanism of Injury or Death


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