• Karolina Brook, Mark J Facchin, Albert A Kalustian, Mauricio GonzalezRRDepartment of Anesthesiology, Boston Medical Center, 750 Albany Street 2R, Boston, MA, 02118, USA.Department of Anesthesiology, Boston University School of Medicine, Boston, MA, USA., Keegan L McDonnell, and Donald H Lambert.
• Department of Anesthesiology, Boston Medical Center, 750 Albany Street 2R, Boston, MA, 02118, USA. Karolina.brook@bmc.org.
• J Clin Monit Comput. 2022 Jun 1; 36 (3): 909-915.

AbstractA Hotline® fluid warmer is a device commonly used by anesthesia providers in the operating room to warm and infuse blood products and large fluid volumes. The purpose of the fluid warmer is to counter heat loss, which occurs under anesthesia. Despite normal checks performed prior to its use, we discovered a breach in the fluid warming set attached to the Hotline® fluid warmer during blood administration. The breach contaminated the patient's sterile intravenous line. We describe the quality and safety processes we undertook in detail. We discuss the notion that monitoring alarms are an important safety feature of most modern devices utilized by anesthesia providers. We believe the Hotline® fluid warmer lacks a crucial monitor for detecting a breach within the fluid warming set, and therefore recommend the addition of an alarm to improve this device's safety.© 2021. The Author(s), under exclusive licence to Springer Nature B.V.

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