Root cause identified in infant warmer fire

A team of nationally-recognized experts has concluded that the fire that occurred in an infant bassinet at Mercy Hospital on Jan. 22, 2008 was most likely caused by a hot particle falling from the bassinet’s warmer assembly into the oxygen-enriched environment near the infant’s head.

Microscopic investigation revealed several sites of overheating and thermal damage in the warmer head area that was the likely source of the particle that fell into the bassinet and caused the fire. The warmer’s design and construction did not adequately safeguard the bassinet from exposure to a hot particle potentially generated and dropped during normal operation.  The actual defects in the heater were not visible to the naked eye and could not be detected by the maintenance, repair, calibration and routine inspection performed by clinical engineering staff.

The warmer involved in the incident was a Hill-Rom 1250. The investigators recommend that Allina no longer use this warmer for any purpose. In addition, they also recommend taking the following similar warmers out of service at Allina: Borning models 200 and 300, and Hill-Rom models 1500, 2000/3000, 2000, 2200/3200, 3000 and 3200. These Hill- Rom model numbers may be followed by the letters A, B or C.

ECRI Institute will soon release a set of recommendations for other health care facilities that use these warmers.

For more information on the Patient Safety Registry, adverse health event reporting or this alert, contact Julie Apold, MHA director of patient safety, at japold@mnhospitals.org or (651) 641-1121 or toll-free at (800) 462-5393.