CARDINAL HEALTH INSULATED GEL PACK

Description of Event or Problem

PATIENT S/P (STATUS POST) TOTAL ABDOMINAL HYSTERECTOMY (HAD BLOCK W/ MARCAINE & EXPAREL PRE-OP). A HEAT PACK WAS USED POST-OP FOR CRAMPING & ABDOMINAL PAIN. A SMALL BLISTERED AREA NOTED AT INCISION W/ SURROUNDING ERYTHEMA. PT RETURNED TO HOSPITAL W/ CONCERN FOR BURN AT INCISION SITE & INFECTION. SHE REQUIRED ADMISSION, PLASTIC SURGERY CONSULT, AND 2 ADDITIONAL PROCEDURES W/ XENOGRAFT PLACEMENT. PT DID REPORT SHE USED HEAT ON HER ABDOMEN AFTER DISCHARGE - UNABLE TO DETERMINE TYPE OF HEATING PACK USED. INVESTIGATION RESULTS: 1) NURSING REPORTED HEATING PACK WAS USED PER MANUFACTURER GUIDELINES AND PLACED ABOVE THE BINDER. 2) UNABLE TO FULLY VERIFY IF BLOCK WAS STILL EFFECTIVE AT THE START OF HEATING PACK USE. 3) ASSESSMENT OF SITE CONSISTENT WITH A BURN - CONCERN NOTED D/T CONSISTENT USE OF HEAT PACK DURING HOSPITALIZATION. 4) MANUFACTURER IFU INCLUDES PLACING PACK IN WRAP - NURSING REPORTS THIS WAS DONE. 5) MANUFACTURER IFU NOTES MICROWAVE AT 750 WATTS. INVESTIGATION ON MICROWAVE USED TO HEAT IS 700 WATTS.