inforMED
MalfunctionLHC

WARMING CABINET

Received Jul 12, 2024 · Event occurred Jul 5, 2024

Report 19729106 · MDR key 19729106

Device

Generic name

Warmer, Irrigation Solution

Model number

5624

Patient

39 YR · Female

  • Hemorrhage/Blood Loss/Bleeding
  • Laceration(s)
  • Hemorrhage/Blood Loss/Bleeding
  • Laceration(s)

Narrative

Description of Event or Problem

STAFF WAS STACKING BLANKETS IN BLANKET WARMER. WHEN THEY GOT TO THE TOP, THEIR RIGHT THUMB HIT THE BOTTOM OF THE MIDDLE SHELF OF THE BLANKET WARMER. THIS CAUSED A CUT THAT BLED FOR APPROXIMATELY AN HOUR. THE CUT REQUIRED STERI-STRIPS TO CLOSE. THE ROOT CAUSE OF THE INJURY IS AS FOLLOWS. THERE ARE HOLES IN THE SHELF FOR AIR CIRCULATION THAT THE BOTTOM OF THESE HOLES HAVE SHARP EDGES. THERE HAS BEEN PREVIOUS INJURIES THAT HAVE BEEN CAUSED BY THESE SHARP EDGES. THERE WAS A PREVIOUS MEDWATCH FOR A SIMILAR GETINGE WARMER, (B)(4). MANUFACTURER RESPONSE FOR WARMING CABINET, WARMING CABINET (PER SITE REPORTER). PER CLINICAL ENGINEERING TECHNICIAN PREVIOUSLY INVOLVED, THERE WERE A FEW SHELVES SENT HOWEVER, THERE WERE SHARP EDGES ON A NUMBER OF THOSE SENT.