ABSTRACT
Healthcare fires have always been one of the major internal hazards and an oxygen-rich environment further aggravates these threats. The present case study reports such a fire incident in an Advanced Trauma Centre of a tertiary care hospital in North India wherein a tiny spark generated while handling an oxygen cylinder a health care worker got caught in a fire blaze. Fortunately, the flare was controlled within no time due to prompt action by a fellow HCW, and a major unexpected incident was averted. A formal investigation conducted by a team of experts ascertained that oxygen enrichment from leaking equipment, improper handling, and repeated striking of cylinder regulator by the spanner which attained the required threshold temperature was the probable cause for the onset of a flare. Henceforth, to miti-gate such incidents users shall follow manufacturer recommendations, and ensure only safe and suitable components are used as part of a compressed oxygen system. Maintenance of cylinders, valves, and regu-lators should be done periodically to mitigate the risks of such incidents. All hospitals shall carry out risk-assessment exercises and provide oxygen safety training to all healthcare staff.