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Infant monitoring resulting in burns-tissue damage: literature review and case report
Insights
Infant monitoring devices can cause serious burns and tissue damage, with improper connections being a common cause. Two infants died from electrocution due to these medical device errors.
Area of Science:
- Medical Device Safety
- Pediatric Patient Safety
Background:
- Noninvasive infant monitoring devices are widely used for patient care.
- Occasional adverse events, including burns and tissue damage, have been reported.
Observation:
- A review of 14 reported cases of infant burns and tissue damage from monitoring devices.
- Victims were all under 24 months of age; two died from electrocution.
- Injuries occurred in hospital (57%) and at home (43%), affecting extremities (40%) and trunk (23%).
Findings:
- Commonly implicated devices include respiratory, pulse oximetry, and electrocardiographic monitors.
- The primary cause was misapplication or improper connection of electrode lead wires (57%).
- One-third of affected infants required reconstructive surgery, such as skin grafts.
Implications:
- Identifies critical risk factors for monitor-induced infant injuries.
- Highlights the need for improved training and adherence to safety protocols.
- Outlines principles for preventing burns and tissue damage during infant monitoring.
Abstract:
Noninvasive infant monitoring occasionally results in burns and tissue damage. The medical literature now contains 14 isolated reports that were summarized for this review. All 14 victims were less than 24 months of age, and of these 14, two died by electrocution. Burns and tissue damage resulted from infant respiratory monitors (six), pulse oximeters (four), electrocardiographic monitors (two), an anal myoneural junction monitor (one), and a fetal scalp monitor (one). Infant extremities were injured most often (40%), and the trunk was burned somewhat less frequently (23%). Infants were burned in the hospital (57%) only slightly more often than at home (43%). Household burns involved only infant cardiorespiratory monitors. The most common mechanism of injury was the misapplication or improper connection of electrode lead wires (57%). A full one third of infants with burns required a reconstructive surgical procedure, usually a skin graft. Risk factors related to monitor-induced burns and tissue damage have been identified and presented. Injury prevention principles are also outlined.