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Hershey Med cited in death of boy, 6, left under heating blanket

Penn State Health Milton S. Hershey Medical Center has been cited by state health officials following the death of a child whose temperature spiked while left unattended under a heating blanket in the emergency department.

The 6-year-old boy died on Jan. 11, but hospital officials did not report the incident to the state until March 29, a June 26 Health Department report on the case states. (Date of report listed in drop-down menu.)

The hospital was cited for failing to report the unexpected death to state officials within 24 hours, as required by state law, and for failure to meet care standards.

When a doctor checked the child at around 10 a.m. on Jan. 11, the child showed no vital signs, and his temperature was 107.6 degrees, the report states. His temperature had not been recorded for more than 10 hours before that, and the doctor determined the heating device, known as a Bair Hugger, “had been on high all night.”

The average body temperature for a human being is 98.6 degrees.

Hershey Med officials released a statement in which they said they only became aware of the incident on March 3, after the Pennsylvania Patient Safety Authority received an anonymous employee letter about the child’s death.

The hospital also says it already has taken corrective action, as required by the state.

Names of the patients and staff involved in the case are not disclosed in the reports.

Chronology

According to the state and hospital reports:

• The child arrived in Hershey Med’s emergency department at 2:51 p.m. on Jan. 10, with a temperature of 89.4 degrees.

• A Bair Hugger was applied to the patient, who “was brought to our emergency department for low body temperature and presumed sepsis,” or a blood infection, Hershey Med stated. The device uses forced hot air to raise a patient’s temperature.

• The child’s temperature was taken four more times, through 12:14 a.m. Jan. 11, when it was 98.0 degrees, the state report says.

That was consistent with medical center policy requiring temperatures of patients under heating or cooling devices to be checked at least every two hours.

• There were no other temperatures documented until 10:22 a.m. on Jan. 11. A doctor found the boy with no vital signs and a temperature of 107.6, the state reports.

“Investigation into this matter revealed that an agency nurse was overseeing the child’s care during the 10-hour gap in temperature documentation, and no one involved in the child’s care reported the incident to our Patient Safety Department or submitted a report through our reporting system,” Hershey Med stated.

• The child was transferred to the pediatric intensive care unit, but died at 5:39 p.m. that day.

Probe and response

News of the incident and response was first reported by medical reporter and blogger Walter F. Roche Jr. last week.

State officials began an investigation on April 12, and ordered Hershey Med to undertake immediate corrective actions, including those related to monitoring patients under heating and cooling devices.

Hershey Med took action the following day, the state reported.

Hospital officials say they also responded to the state’s formal notice of citations, issued on June 26.

“This situation raised serious issues, and our response has been equally serious,” the hospital’s statement indicates.

“As an organization that holds itself accountable for providing the highest quality care while protecting the safety of patients, employees and visitors, we recognize this situation as an unacceptable failure. We expect more of ourselves as a system and as individuals committed to the highest standards of care for each person we serve,” Hershey Med continued.

“We have responded with the utmost of focus and determination to do better. During the DOH on-site investigation, we immediately developed a corrective plan of action for each issue identified. Just as importantly, we launched our own investigation to determine what happened, how it happened and how to prevent it from ever occurring again.”

Roger DuPuis
Roger DuPuis covers Cumberland County, health care, transportation, distribution, energy and environment. Have a tip or question for him? Email him at [email protected].

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