• Thermal injuries. The most frequently reported type of patient
harm in Ms. Feil's report come in a variety of forms, but they nearly
all stem from the same root cause: Using warming devices in a man-
ner that's not consistent with the manufacturers' Instructions for
Use (IFU). For example, the report cited an example of a patient
who'd been lying directly on top of a warming blanket during an
appendectomy, which resulted in reddening of his skin and a small,
reddened area on the right buttock. That usage went against the
blanket's IFU, which specifically stated patients should never be
positioned on top of the blanket, that they should only be covered
by it.
Then there's the extremely dangerous practice of "free hosing,"
where the hose of a forced-air warming device is placed underneath
surgical drapes or the blanket of a patient's bed or stretcher. This off-
label use has resulted in a number of cases of serious patient burns
because of the change in the distribution of the heat.
"If you place a hose underneath the drapes, you're focusing a very
concentrated amount of heat in one area," says Victoria M. Steelman,
PhD, RN, CNOR, FAAN, a patient safety expert and an associate pro-
fessor at the University of Iowa College of Nursing in Iowa City. "And
patients generally can't tell you if they're being burned."
Another seemingly harmless free-hosing practice that is anything
but: Putting the hose under a blanket to warm the bed when the
patient isn't on it yet. "That's not filtered air," says Dr. Steelman. "The
practice creates aerosolized fibers from the blanket, and that's not a
prudent thing to do."
It's not just the warming devices and blankets that are being used
incorrectly and opening up patients to safety risks. Warming IV or
irrigation fluid is a useful adjunct to patient warming that has shown
to be effective in preventing hypothermia when combined with
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