Root cause identified in infant warmer fire
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.
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.
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
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.
Institute will soon release a set of recommendations for other health care facilities that use
For more information on the Patient Safety Registry, adverse
health event reporting or this
alert, contact Julie Apold, MHA director of patient safety, at [email protected] or (651) 641-1121 or toll-free at (800) 462-5393.