when staff members aren't closely monitoring a patient's temperature
or using warming devices correctly.
The Pennsylvania Patient Safety Authority's report says a surgical
staff member set a warming blanket's temperature to 40°F instead of
the desired 40°C. Because the patient was inadvertently being cooled,
his body temperature dropped all the way down to 34.7°C (94.4°F), and
he wound up being taken to intensive care postoperatively.
You must also be aware of the potential to overwarm patients, espe-
cially during cases in which most of the patient's body remains cov-
ered, such as procedures performed on head and neck areas, and dur-
ing surgeries performed on pediatric patients.
"With kids, for something like a simple ear procedure, you can get
them all covered up and put a warming device on them, then suddenly
their temperature or their heart rate goes up," says Dr. Austin.
These scenarios highlight a major problem with patient warming pro-
tocols: A lack of continuous patient temperature monitoring.
"Recommendations suggest monitoring patients' temperatures in pre-
op, during surgery and in post-op," says Dr. Steelman. "But staff in a lot
of facilities do it just once in pre-op, and once in post-op.
"There's no reason that continuous monitoring can't be done," she
adds, "because there's technology that lets staff do it in a non-inva-
sive way."
For example, a temperature monitoring system is available that
involves placing a disposable sensor on the patient's forehead.
The sensor, which travels with the patient, connects to small con-
trol units placed in pre-op, the OR and PACU that display digital
temperature readings.
• Equipment issues. Ms. Feil's report cited equipment problems as
one of the top safety issues associated with patient warming. Often
these issues are maintenance-related and can be avoided altogether
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