Executive Summary
A hospital is being sued by the parents of a newborn who was seriously burned during a routine testing procedure. The nurse used a method for improving blood draws that is forbidden at most hospitals, according to the plaintiff’s attorney.
-
The nurse was drawing blood for the routine PKU test on the newborn.
-
Staff members explained that a hot diaper was applied to the baby’s foot to improve blood flow, the attorney says.
-
The baby suffered serious second-degree burns.
A Houston, TX, hospital is facing a lawsuit after a newborn was seriously burned in an attempt to draw blood, and the incident could be a warning bell that techniques formally banned as too dangerous might still be performed in your hospital.
Newborn Isabel Lewandowski was burned when a nurse tried to increase blood flow to the baby’s foot by applying a hot disposable diaper to the skin, says Houston attorney Tim Culberson, JD, who is representing the family in the lawsuit against St. Joseph Medical Center in Houston. After the baby was injured, staff members told the parents that the hot diaper was applied to the skin to facilitate the blood draw for the routine phenylketonuria (PKU) test, Culberson says.
Clinicians have explained to Culberson that it is sometimes difficult to draw enough blood from the baby’s heel, where the stick is usually done, so the heat is applied in an attempt to increase blood flow to the area.
“From what I understand, back in the old days, nurses used to take cloth diapers and put them in warm or hot water and apply that to the heel for the PKU. It became known as a neat trick among the nurses, an effective way to get the blood drawn, and it was adopted by a lot of hospitals,” Culberson explains. “Eventually a lot of babies started getting burned, and they stopped doing that. Risk managers at hospitals pretty much outlawed the practice and said ‘we’re not doing this anymore.’”
In the Lewandowski case, Culberson says a nurse in her mid-40s tried to use a modern disposable diaper in the same way. Two factors worked against her: First, disposable diapers contain a gel that expands when wet and can retain a great deal of heat. Second, she reportedly heated the wet diaper in a microwave. As anyone who has reheated food in a microwave knows, the substance can be extremely hot in some spots while only warm to the touch in other areas.
“So she had a diaper with an unknown amount of heat in it, in a gel that holds and transfers that heat very well, and she wrapped that around the baby’s foot,” Culberson says. “The practice has been banned for years, but somehow this nurse knew about it and got the idea that this was a good thing to do.”
St. Joseph Medical Center issued a statement acknowledging the lawsuit. Hospital leaders say they are conducting a thorough investigation of the incident.
It is not yet clear whether the nurse had used the technique previously on other newborns or whether it was an openly accepted practice in the hospital, Culberson says. However, since the news broke of the Lewandowski baby’s injury, parents from across the country have called Culberson to report the same injuries to their children.
Risk managers should see this case as a warning that techniques formally banned by the hospital still might be used surreptitiously, Culberson says. There also might be a need to caution clinicians about using “tips and tricks” that are passed along from other clinicians or ideas they come up with on their own, he says.
“My understanding is that the old school method with the diaper was eliminated many years ago, so I don’t think a nurse of this age would have used it before and resurrected it,” Culberson says. “So you have to wonder if it was something the nurses heard about from back in the old days and wanted to try, or if maybe they just knew that heat would help and came up with this way to apply it. Either way, it resulted in a terrible injury to this child.”
