Surgery Center Accreditation Fire Drill

Mandatory Quarterly Fire Drill

Surgery Center Accreditation Fire Drill
Surgery Center Accreditation Fire Drill Evacuation

Fire Drills are mandatory and have to be conducted on a quarterly basis to maintain your surgery center accreditation and Medicare deem status certification for the surgery center. New mandates dictate that the individual in charge of initiating the drill (this person is deemed as the safety officer) must also submit to the Quality Committee a written critique evaluating the fire drill along with the actual documentation of the fire drill.


Surgery Center Activation of the Pull Station
Surgery Center Accreditation Activation of the Fire Alarm


The Fire Drill Procedure must include evidence of the following components:

  1. Alerting the fire alarm monitoring company of fire drill. You must activate a signal during all drills whether pulling the fire pull station or setting off a smoke alarm.
  2. Staff compliance to the evacuation “RACE” procedure (REMOVE-ALARM-CLOSE-EVACUATE).
  3. Make sure all staff is aware of the safe refuge area during Evacuation.
  4. Be aware of how many individuals are in the waiting area. Upon hearing the alarm make a head count and instruct all occupants to the nearest exit. Ensure all waiting area occupants walk safely and keep to one side to evacuate the building and proceed to a safe refuge area.
  5. Any occupant in the waiting area with a physical disability should be assigned to a front office staff member. For example a man in a wheel chair should have assistance in exiting the building.
  6. Make sure a staff member is responsible for shutting off all medical gas and closing all doors.
  7. Ensure that the RN and Surgeon is responsible to escort patient in OR to safety and PACU RN’s and back office staff assist PACU patients to safety.
  8. For Medicare deem status facilities remember the DEFEND IN PLACE policy. Facilities that are Medicare deem status have fire rated protective barriers where the patient and Medical Staff have the option to “DEFEND IN PLACE “and there location must be reported to the safety officer.
  9. At safe refuge area take head count. Verify everyone has evacuated and is accounted for. Report the location of any occupants who are physically impaired or any occupants “defending in place” to safety officer at refuge area.

Upon complete evacuation of the building, the safety officer will inform you when you may return to the building.


Surgery Center removal of patient during fire drill
Surgery Center Accreditation removal of patient during fire drill



Surgery Center evacuation of patient from PACU
Surgery Center Accreditation removal of patient from PACU during fire drill



Special thanks to Catherine Tinnion, RN, CNOR & Safety Officer for leading the fire drill at Beverly Surgery Center.


Surgery Center fire drill
Surgery Center Accreditation Fire Drill Evacuation


Here’s to your success,


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