ECRI Institute, which participated in the root cause analysis of the Minnesota bassinet fire, has issued an important equipment alert. This alert lists the manufacturers and model numbers of infant radiant warmers that have heater elements which ECRI feels have an increased risk of precipitating fires. Your facility needs to determine whether any such units are in use and remove them.
You’ll recall the unfortunate incident at Mercy Hospital in Coon Rapids, Minnesota of in which a neonate suffered burns in a flash fire while in an open-topped bassinette under a warmer while using an oxygen hood (see our January 29, 2008 Patient Safety Tip of the Week “Thoughts on the Recent Neonatal Nursery Fire” and our April 2008 What’s New in the Patient Safety World column “More Neonatal Incubator Fires”). Though nurses promptly extinguished the flames, the infant suffered burns over about 18% of his head and body.
Since that time there have been even more neonatal injuries and fatalities related to incubator fires in India.
Not only do you need to make sure you are no longer using one of the bassinet warming devices in the ECRI alert, but we’d suggest your organization consider performing a FMEA (failure mode and effects analysis) on potential neonatal unit fires. We had hoped by now we’d have several root cause analyses available to provide valuable lessons learned on these neonatal unit fires. However, details have not been published on any of the Indian cases. The executive summary of the Coons Rapids fire investigation is available and is a great place for you to start since it nicely outlines multiple theoretical concerns that you should be addressing. Focus, of course, is on all the components of the fire triad: an oxydizer, a heat source, and a fuel. That summary identifies the multiple potential heat sources you need to consider that could trigger a fire in an oxygen-rich environment. And, as we had expected in our previous columns, it does address potential fuels such as the alcohol-based disinfectants that we use so commonly now in our hospitals. The executive summary of the Minnesota incident does not go into much detail about oxygen but we have previously recommended that hospitals take a careful look to ensure that the clinical indications for use of oxygen are carefully adhered to. Just as in our discussions about the unnecessary use of urinary catheters, undoubtedly there are circumstances where neonates or other patients are “reflexly” begun on oxygen. (Worse yet, we know that reimbursement policies sometimes have the unintended consequence of unnecessarily prolonging oxygen therapy in neonates). Hospitals should have evidence-based criteria not only for starting oxygen therapy but also for its continuation and discontinuation.
Just as we need to ensure that everyone who enters an operating room has had appropriate training in surgical fire risk and procedures, we now need to consider similar training of everyone for any area in which oxygen is being used. This obviously would include not only staff, but everyone who might enter that area. That would include housestaff, agency personnel, and even parents and other visitors.
ECRI Institute High Priority Medical Device Alert
Infant Radiant Warmer Fire Prompts ECRI Institute Recommendations for Replacement.
Kanwar S. Concern focuses on patient safety. The Times of India. February 1, 2009
Allina Hospitals & Clinics. January 15, 2009