Description of Event or Problem · 0
ON (B)(6) 2024, A 57-YEAR-OLD HOSPITALIZED PATIENT REQUESTED A HEATING PAD FOR BACK PAIN. THE NURSE PLACED A SMI GEL BAG ON THE PATIENT'S LOWER BACK AT AROUND 10PM. THE NURSE HEATED THE GEL BAG FOLLOWING THE INSTRUCTIONS PRINTED DIRECTLY ON THE GEL BAG. "HEAT THE GEL BAG(S) IN THE MICROWAVE AT FULL POWER FOR ONE (1) MINUTE. CONTINUE TO HEAT AT FULL POWER IN 30 SECONDS INTERVALS UNTIL THE GEL BAG IS WARMED EVENLY TO THE TOUCH. USE EXTREME CAUTION! DO NOT OVERHEAT THE GEL BAG IN THE MICROWAVE AS THIS MAY CAUSE SEVERE BURN. CAREFULLY PLACE THE HEATED GEL BAG(S) INTO THE GEL POUCH AND APPLY TO THE AFFECTED AREA. NEVER APPLY HEATED GEL BAGS DIRECTLY TO THE SKIN. ALWAYS USE GEL POUCH DURING YOUR TREATMENT." (EMPHASIS IN ORIGINAL) IN THIS CASE, THE NURSE HEATED THE GEL BAG IN THE MICROWAVE FOR 1 MINUTE OR 1 ½ MINUTES. SHE THEN HELD THE HEATED GEL BAG WITH HER BARE HANDS TO ASSESS THE TEMPERATURE AND THEN WRAPPED IT IN A PILLOWCASE BEFORE APPLYING IT TO THE PATIENT. SHE REMOVED THE GEL BAG ON (B)(6) 2024, AT AROUND 2AM. DURING HER ASSESSMENT, THE NURSE OBSERVED 2 INTACT BLISTERS LOCATED AT THE AREA WHERE THE GEL BAG WAS PLACED. APPROPRIATE TREATMENT AND FOLLOW-UP WERE PROVIDED. AN RCA WAS CONDUCTED ON (B)(6) 2024. PRIOR TO THE RCA, THE HOSPITAL'S SUPPLY CHAIN MANAGER CONTACTED THE PRODUCT'S VENDOR WHO STATED THAT ALL FACILITIES SUPPLIED WITH THE SMI GEL BAGS HAD RECEIVED EDUCATION TO USE THE PRODUCT EXCLUSIVELY FOR COLD THERAPY. THE VENDOR AGREED TO PROVIDE REINFORCEMENT EDUCATION. TO HELP PREVENT INADVERTENT MISUSE IN THE FUTURE, WE ALSO REQUESTED THAT THE VENDOR PROVIDE AN EQUIVALENT PRODUCT BUT WITHOUT THE HEAT THERAPY INSTRUCTIONS PRINTED ON THEM. IN THE MEANTIME, THE UNIT'S MANAGER COMMUNICATED TO HER STAFF TO STOP USING THE SMI GEL BAGS FOR HEAT THERAPY IMMEDIATELY. ADDITIONALLY, RISK MANAGEMENT ISSUED AN ALERT TO OTHER FACILITIES WITHIN THE ORGANIZATION TO STOP USING THE SMI GEL BAGS FOR HEAT THERAPY.