NOVAPLUS INFANT HEEL WARMER

Description of Event or Problem

REGISTERED NURSE (RN) ACTIVATED THE HEEL WARMER AS USUAL AND PLACED IT ON INFANT¿S HEEL. NURSE BEGAN ASSESSMENT AND MID ASSESSMENT (~2 MINUTES), THE HEEL WARMER POPPED/EXPLODED AND THE CONTENTS SPLATTED AGAINST INSIDE OF ISOLETTE- ON BLANKETS, WALL OF ISOLETTE AND OUT OF PORTHOLE DOOR ONTO FLOOR. SEAM POPPED OPEN, CONTENTS OF PACKAGE WENT ON INFANT¿S BILATERAL LOWER LEGS, BELOW THE KNEES, AND BEDDING CHANGED. HEEL WARMER PROMPTLY REMOVED AND INFANT CLEANED OF CONTENTS.