Children's Hospital Association: Preventing Thermal Injuries and Pediatric Harm

By Kerri Kuntz

A newborn infant was unable to regulate his body temperature in the first few hours after birth. A nurse made an improvised heat pack of hot water from an instant hot water dispenser and tucked it under the newborn’s side to warm him.

The nurse was newly off orientation as a graduate, and her preceptor showed her how to make a heat pack for this purpose. She was unaware the temperature of the heat pack was too hot for the newborn’s fragile skin, and the baby suffered full thickness burns on his thigh and buttock area, requiring plastic surgery and skin grafts.

While this was not an event at Children’s Mercy Kansas City and it occurred 20 years ago, thermal injuries like this occur in hospitals every day and cause wounds, pressure ulcers, severe burns, blisters and scarring to pediatric patients.

As Children’s Mercy began to investigate the use of thermal products and devices in the organization, areas of risk began to reveal themselves. The hospital used real safety stories like the one above, along with photos of thermal injuries, to get the attention and buy-in of stakeholders.

It took seven months once the hospital completed the thermal injury risk assessment to fully implement the action plan. Nearly two years have passed, and the hospital has not had a single thermal injury report. The work group continues to monitor for thermal injuries, and members are actively trying new ways to operationalize risk assessments.

Members of the executive leadership team began asking for completion of new risk assessments as they became available from the Child Health PSO. Depending on the type of risk assessment, the process will look different as stakeholders vary. But by using the existing infrastructure to complete risk assessments, the hospital has made progress to improve patient outcomes.

Read the full story via Children's Hospital Association 

Learn more about Quality and Safety at Children's Mercy