General Hospital • Operating Theatre

Fire Drill Evaluation Form

1. Drill Scenario

2. Response Evaluation

Action / Observation Yes No N/A
R - Rescue (Life Safety First)
Did the team immediately prioritize the safety of the "patient"?
Was the burning item removed from the patient/field safely (if simulated)?
A - Alarm (Alerting Help)
Was the alarm raised clearly and audibly ("FIRE IN OR X")?
Was the nearest fire pull station activated (simulated)?
Was the Charge Nurse / incident command notified promptly?
C - Contain (Preventing Spread)
Was the ignition source turned off (e.g., ESU unplugged/shut down)?
Were medical gases/oxidizers shut off appropriately (anesthesia coordination)?
Were OR doors closed to contain smoke and fire?
E - Extinguish / Evacuate & P.A.S.S.
Did staff locate the nearest correct fire extinguisher quickly?
Did staff verbalize/demonstrate correct P.A.S.S. technique?
Was the evacuation route identified and confirmed clear of obstructions?
Did the team demonstrate knowledge of the patient evacuation protocol?
Leadership & Communication
Did a clear leader emerge to direct the response (e.g., Surgeon/Charge Nurse)?
Was communication clear, closed-loop, and free of panic?

3. Post-Drill Debriefing & Action Plan

Drill Evaluator

OT Nurse Manager (Review)

FMS / Safety Officer