Bassinet fire investigation complete
Expert panel concludes defect in infant warmer most likely caused
January 2008 incident at Mercy Hospital
MINNEAPOLIS, Minn. 01/15/2009--A team of nationally-recognized experts has concluded that a small fire that occurred in an infant bassinet at Mercy Hospital on January 22, 2008, was most likely caused by a hot particle falling from the bassinet's warmer assembly into the oxygen-enriched environment near the infant's head.
 Download an executive summary of the investigators' report here.
The investigation was carried out by engineers from ECRI Institute of Plymouth Meeting, Pa., Exponent Failure Analysis Associates, Inc. of Menlo Park, Calif., and Wendell Hull & Associates of Los Cruces, N.M. Rigorously scientific protocols, agreed upon by all interested parties, were used throughout the investigation.
The attorney for the family of the infant, government regulators, representatives of all device manufacturers and others were invited to observe and comment on the investigation's methodology and scope, with some 30 individuals present to observe the inspection of the evidence. The investigation included chemical, electrical, mechanical, electrostatic, metallurgical and thermal analysis on all equipment and materials present at the time of the incident, as well as on other similar equipment. Additional testing at offsite laboratories was subsequently conducted to follow up on every possible lead.
"We are satisfied that we now know what caused this terrible accident," said Penny Wheeler, MD, Allina's chief clinical officer. "Patient safety is our top priority and we are confident that taking the warmers identified by the investigators out of service at Allina will prevent anything like this from happening again. We continue to keep the child and his family in our thoughts and prayers."
Microscopic investigation revealed several sites of overheating and "thermal damage" in the warmer head area that was the likely source of the particle that fell into the bassinet and caused the fire. Because the actual defects in the heater are not visible to the naked eye, investigators concluded that "the maintenance, repair, calibration and routine inspection performed by Mercy Hospital clinical engineering staff. . . was appropriate and did not cause the generation of the ignition source."
The report concludes that "the warmer's design and construction do not adequately safeguard the bassinet from exposure to a hot particle potentially generated and dropped during normal operation."
The investigation ruled out any action on the part of the hospital staff or malfunction of other medical devices in use at the time as causes of the fire.
Mercy Hospital had not used continuous oxygen therapy for newborns since the incident, and babies needing this treatment have been transferred to other hospitals. As the investigation is now complete, Mercy Hospital is now making this treatment available again.
The warmer involved in the incident was a Hill-Rom 1250. The investigators recommend that Allina no longer use this warmer for any purpose. In addition, they also recommend taking the following similar warmers out of service at Allina: Borning models 200 and 300, and Hill-Rom models 1500, 2000/3000, 2000, 2200/3200, 3000 and 3200. These Hill-Rom model numbers may be followed by the letters A, B or C.
Immediately after the fire occurred, Allina discontinued the use of the model of warmer that was involved in the incident. Subsequently, Allina also stopped using several other warmer models with similar design and construction, and now no longer uses any of the models listed above.
ECRI Institute will soon release a set of recommendations for other health care facilities that use these warmers.
Background
On January 22, 2008, a fire incident occurred at Mercy Hospital in Coon Rapids, Minn., that resulted in burn injuries to a newly born infant. The infant was in a bassinet under a radiant warmer being supplied oxygen to assist in breathing. Approximately 11 hours after the birth, there was a fire in the bassinet that was quickly extinguished by the attending nurses. The infant survived the fire, but sustained burn injuries. The infant was transferred to Hennepin County Medical Center for treatment of his burns and was discharged within a few days. Allina Hospitals & Clinics immediately began the thorough, comprehensive investigation that is now concluded.
Download the executive summary of the investigative report.
Allina Hospitals & Clinics is a not-for-profit health care system of hospitals, clinics and other patient care services that provides exceptional care to communities throughout Minnesota and western Wisconsin and employs more than 22,000 people. Information about Allina Hospitals & Clinics can be found online at www.allina.com.
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Related Links
01/15/2009 - Executive summary of the investigative report (requires Adobe Reader)
01/15/2009 - Minnesota Patient Safety Alert: Bassinet fire investigation complete (requires Adobe Reader)
01/25/2008 - Allina Hospitals & Clinics engages national experts to investigate nursery fire
01/23/2008 - Statement about incident involving infant at Mercy Hospital
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