Cause of Device-Related Incident
Device factors; User errors

Clinical Specialty or Hospital Department
CCU / ICU / NICU; Nursery; Nursing; Pediatrics

Device Factors
Device interaction

Document Type
Hazard Reports

External Factors
*Not stated

Mechanism of Injury or Death
Failure to deliver therapy; Fire; Suffocation

Support System Failures
*Not stated

Tampering and/or Sabotage
*Not stated

User Errors
Incorrect clinical use

UMDNS
Warmers, Radiant, Infant [13-249]; Warmers, Radiant, Infant, Mobile [17-433]; Warmers, Radiant, Infant, Stationary [17-956]; Warmers, Radiant, Infant, Transport [13-251]

Unshielded Radiant Heat Sources



Hazard [Health Devices Nov 1983;13(1):27-8]

Problem

A member hospital reported that heat radiating from an infant warming lamp caused two nearby compressed air hoses to burst. Although a patient was in an incubator below the warming light at the time of the incident, no injury occurred. However, the reporting hospital expressed concern that a fire could result if such a rupture occurred in an oxygen hose.

Discussion

The warming lamp involved was a gooseneck fixture that uses two 250-watt bulbs with reflective metal backing. The hoses, which were connected to overhead compressed air outlets and were supplying air to an O2 blender and ventilator, were inadvertently draped close to these bulbs. We created a similar setup in our laboratory and tested hose samples identical to those that ruptured to determine whether the hoses burst due to heat radiating from the bulbs or from contact with the hot lamp. Within two minutes of placing a hose 2.5 cm from a hot lamp, the hose softened, developed a bulge on the side facing the lamp, and finally burst loudly. Placing the hose in direct contact with the lamp caused it to melt and rupture. Since there was no evidence of melting on the hoses in the reported incident, we believe that radiant heat caused the hoses to rupture.

To assess the potential for a fire resulting from such a rupture, we substituted oxygen pressurized at 55 psi for the compressed air. As before, the hose softened and burst when exposed to radiant heat, but did not spontaneously ignite. While this may suggest that the chance of fire is minimal, combustible objects near the point of rupture (and, thus, close to the lamp) or hoses of more combustible composition from other manufacturers could be ignited in an oxygen-enriched atmosphere.

While the reported incident involved a specific model of infant warming light, most perinatal and general-use heat lamps are of the gooseneck style and pose similar risks. Very often, bulbs and other hot surfaces (e.g., metal reflectors) are not adequately shielded, resulting in increased risk of damage to the bulb as well as burns to personnel (especially during close procedures) and equipment damage.

Recommendations

  1. Keep hoses, as well as electric cords and patient leads, and other flammable objects (e.g., drapes, towels) away from any heat source. This is especially important for hoses carrying combustion-supporting gases (e.g., oxygen, nitrous oxide).
  2. Avoid using radiant heat lamps that lack protective shields. Such lamps are easily damaged and can burn personnel or damage other equipment. Lack of protective shielding also increases the risk of igniting nearby flammable objects.
  3. Hospitals that own radiant heat lamps without protective shielding should contact the manufacturer to see if modifications are available.

UMDNS Terms

  • Warmers, Radiant, Infant [13-249]
  • Warmers, Radiant, Infant, Mobile [17-433]
  • Warmers, Radiant, Infant, Stationary [17-956]
  • Warmers, Radiant, Infant, Transport [13-251]

Cause of Device-Related Incident

Device factor: Device interaction

User error: Incorrect clinical use

Mechanism of Injury or Death

Failure to deliver therapy; Fire; Suffocation


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