An inherently dangerous fluid warmer design

Autor:	Albert A Kalustian, Keegan L McDonnell, R. Mauricio Gonzalez, Karolina Brook, Mark J Facchin, Donald H. Lambert
Rok vydání:	2021
Předmět:	Fluid administration ALARM Anesthesiology and Pain Medicine medicine Heat losses Environmental science Health Informatics Medical emergency Fluid warmer Critical Care and Intensive Care Medicine medicine.disease human activities
Zdroj:	Journal of Clinical Monitoring and Computing. 36:909-915
ISSN:	1573-2614 1387-1307
DOI:	10.1007/s10877-021-00786-x
Popis:	A Hotline® fluid warmer is a device commonly used by anesthesia providers in the operating room to warm and infuse blood products and large fluid volumes. The purpose of the fluid warmer is to counter heat loss, which occurs under anesthesia. Despite normal checks performed prior to its use, we discovered a breach in the fluid warming set attached to the Hotline® fluid warmer during blood administration. The breach contaminated the patient's sterile intravenous line. We describe the quality and safety processes we undertook in detail. We discuss the notion that monitoring alarms are an important safety feature of most modern devices utilized by anesthesia providers. We believe the Hotline® fluid warmer lacks a crucial monitor for detecting a breach within the fluid warming set, and therefore recommend the addition of an alarm to improve this device's safety.
Databáze:	OpenAIRE
Externí odkaz:	https://explore.openaire.eu/search/publication?articleId=doi_________::6e7da0a30185b2f4ad5a82126e89f02d https://doi.org/10.1007/s10877-021-00786-x Zobrazit plný text záznamu Full text from SpringerLink