Bassinet Warmer that Burned Baby Recalled by Company

Scott Wallask, for HealthLeaders Media , July 28, 2009

A medical equipment company has issued a voluntary recall of a line of infant bassinet warmers, stemming from a 2008 flash fire that burned a newborn.

In its July 20 recall, Draeger Medical, Inc.—which is based in Germany and has U.S. offices in Telford, PA—targets Stabilet infant warmer models 200, 300, 1250, 1500, 200/3000, 2000, 2200/3200, 3000, and 3200.

Draeger wants hospitals with Stabilets to take the following actions:

  • Plan to remove the models from service and replace them with alternate warmers if available

  • If Stabilets are the only available warmers in-house, hospitals should begin budgeting for replacements, limit Stabilet use to infants not requiring oxygen therapy, and clearly warn nurses about the recall of the models. Hospitals can use an infant incubator for babies who need warming and are receiving oxygen services.

  • Once removed from service, remove the heating element from the Stabilet warmers and sever the power cords

The fire in question occurred January 22, 2008, at Mercy Hospital in Coon Rapids, MN. A day-old baby was in an open-topped bassinet under a warmer and using an oxygen hood when something ignited, burning the boy. Nurses attending to the infant quickly extinguished the flames.

The ECRI Institute, a healthcare research company in Plymouth Meeting, PA, investigated the fire and determined a Hill-Rom Stabilet radiant warmer was the source of the fire.

Stabilets were originally manufactured by Hill-Rom Company, Inc., in Batesville, IN, and it discontinued the line in 1998 and stopped serving the products in 2003. Draeger acquired the Stabilet line from Hill-Rom in 2004.

Microscopic investigation revealed several sites of overheating in the warmer that were the likely source of the particle that fell into the bassinet and caused the fire. Maintenance activities wouldn't have picked up such damage because it was invisible to the naked eye, according to Mercy Hospital.

Draeger wasn't allowed to test the warmer involved in the incident, says Glenyce Scott-Hoglund, a marketing communications manager for the company.

"Only the hospital's hired experts, ECRI, have been given access to test and evaluate the evidence collected concerning the incident," Scott-Hoglund says. "This is the decision of the hospital."

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