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Topic: Care Management
Publication Type: Medical Safety Information
Single or Multiple Incident: Multiple
Date: 4/1/2008 12:00:00 AM
Country: Japan
Organization: Japan Council for Quality Health Care

This alert discusses multiple patient safety incidents where use of a hot water bottle resulted in a burn injury to the patient. Two incidents are described in detail. In one case, Nurse A prepared a 60˚C hot water bottle because the lower body of the patient felt cold. The bottle was placed on both lower thighs. An hour later, Nurse B removed the hot water bottle, because the patient no longer felt cold. Ten hours later, the nurse noticed erosion and effusion on the lower thigh, and determined that a burn had occurred. Avoiding direct body contact with the hot water bottle was shown in the nursing practice instruction at the hospital, but this was not thoroughly known among nurses.

Additional Details

Device:
hot water bottle


Burn during use of a hot water bottle