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<p>Any unexpected or unintended incident which could have or did lead to harm to one
or more patients can be recorded on the Learn from Patient Safety Events (LFPSE) service,
to support local and national learning. This would include incidents caused by surgical
fires or burns.</p><p>Providers are encouraged to foster a positive safety culture
among their staff, and ensure an appropriate local focus on incident recognition,
recording, and response.</p><p>Recording onto LFPSE is a voluntary process, except
where reporting to NHS England fulfils duties for other statutory mandatory requirements,
such as reporting notifiable incidents to the Care Quality Commission (CQC). NHS England
shares all such data with the CQC. Notifiable incidents include events resulting in
“serious harm” or the death of a service user, and therefore the most serious surgical
fires or burns are subject to mandatory reporting. However, providers are encouraged
to record all patient safety incidents, irrespective of the level of harm, to support
local and national learning.</p><p>Published National Safety Standards for Invasive
Procedures include a requirement for a risk assessment and management plan to minimise
the risk of surgical fires in the perioperative environment. They require that multidisciplinary
team training should involve rehearsal and analysis of typical and emergency scenarios,
such as a surgical fire, and that prior to surgery, any fire risk and the management
plan are discussed and confirmed.</p><p>LFPSE is not designed for performance management.
However, it supports certain oversight functions within providers, including the ability
to review all records submitted by staff, and to mark them as either meeting certain
other requirements, such as notification to the CQC, or not. This supports good governance
within the provider, encouraging scrutiny of recorded events, and the fulfilment of
other statutory or national policy reporting requirements. LFPSE data is being made
available to integrated care boards and regional teams to facilitate their roles in
safety oversight and provider improvement support.</p><p>NHS England does not hold
or collect information on the number of surgical fires which occur. Although incidents
where serious harm and death are captured within LFPSE, and trusts may choose to record
lower levels of harm, there is no category for surgical fires within the existing
reporting system with which they could be counted and therefore any count would not
be definitive.</p>
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