We used kc m1000 made by halyard intraoperative warning system in 2 cardiac surgery pts and both had second degree burns on their back which prolonged their hospital stay and required wound care at home.This system uses gel pads that get applied to pt's back and water runs through the pads to provide heat to keep the pt warm during surgery.This system is used in many hospitals across the usa and internationally.We stopped using the device after those 2 incidents.(b)(4) (pt safety investigation) done.Incident disclosed to the pts.Kc company was informed of the incidents and the decision to stop using their product.The 2 pts were having cardiac surgery with cardio-pulmonary bypass.
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