OR Fire Drills

Q: We just had an accreditation survey and the surveyor cited us for not having a separate fire drill in the Operating Room Suite. I don’t see this in any code or standard.

A: You are correct in saying that there is no standard which requires a fire drill to be performed in the surgery department. However, there are circumstances where this would be expected, and a surveyor could cite you for not conducting a drill in the OR. Here are some situations that would lead a surveyor to believe a fire drill should be conducted in the operating rooms:

  • Surveyor preference. It is possible that the surveyor has a prejudice for fire drills in the Surgery department. If he/she failed to provide a reason why they cited this finding, then it may be presumed they just did so, because they think it should be done; not because it needs to be done. The surveyor needs to say why a fire drill is needed in the Surgery department.
  • Previous history. If there has been a historical event in your Surgery department (such as a fire during a surgical procedure), then it is a reasonable expectation by the surveyor that you address this issue with fire drills. However, if this is the case, the surveyor needs to state the reason why they are citing you for not conducting fire drills in the Surgery department.
  • Lack of documented response during fire drills. According to accreditation standards, staff must participate in fire drills. This does not mean that a fire drill must be conducted in every unit in the hospital, as staff on the 1st floor may participate in a drill conducted on the 4th floor, as long as the building’s fire alarm system was activated. If the source of the alarm was on the 4th floor, staff on the 1st floor are still expected to participate, by closing doors, and preparing to receive evacuated patients. In many hospitals the expectation is to suspend the start of surgeries during a fire alarm until the ‘all-clear’ signal is given. The way to document that all staff participate in fire drills is to have observers on select units and floors to document what the staff did. If you have no documentation that someone observed how the staff in Surgery responded to the alarm, then I can see where the surveyor may have a legitimate concern for a finding.

If in fact you do have documentation that observed the Surgery staff’s response during a fire drill, then that should qualify as participating in a drill.