Hospital Bed-Associated Deaths -- Canada, United States
Between January 1982 and April 1983, three children were killed
when they became caught between the fixed and bottom frames of
automatic, electrically operated hospital beds. The children--a
3-year-old girl in Michigan, a 6-year-old boy in Ontario, Canada,
and
an 11-year-old boy in Illinois--were all ambulatory hospital
inpatients at the time of death. The "walk-away down" switch on
each
child's hospital bed had been activated, presumably by the child;
after one touch, this switch automatically lowers the bed fully
from
its highest position. Each child had crawled beneath the bed's
descending frame, which supports the mattress, and then had been
crushed between the descending frame and the fixed frame at the
bottom
of the bed. The children were subjected to approximately 600
pounds
of force because of the pincer-like action of the closing frames.
The
beds involved in Michigan and Illinois were Hill-Rom, Inc., model
840
hospital beds.* In Canada, the bed involved was manufactured by
Dominion Metal Industries.*
Reported by Bureau of Medical Devices, Health Protection Br,
Environmental Health Directorate, Ministry of Health and Welfare,
Canada; National Center for Devices and Radiological Health, Food
and
Drug Administration; Special Studies Br, Chronic Diseases Div.,
Center
for Environmental Health, CDC.
Editorial Note
Editorial Note: The combination of the children's apparently
activating the "walk-away down" switch and being caught between the
descending and fixed frames caused the three deaths. This switch
has
been promoted by manufacturers as a safety feature because it
assures
that a bed is fully lowered, thereby lessening the severity of
possible injury if a patient falls from the bed. Falls from
hospital
beds are a well-known problem, especially among elderly patients
(1).
In response to these deaths, the Health Protection Branch (HPB)
in
Canada and the Food and Drug Administration (FDA) in the United
States
alerted all hospital administrators to the problem. The HPB
recommended that (1) the switches on electrically operated beds be
of
a type that stops all movement if pressure is released, (2) all
electromechanical components of electrically operated beds be
fitted
with covers to prevent unauthorized access or tampering, and (3)
switches on electrically operated hospital beds already in use be
replaced with the type of switch indicated above.
The FDA recommends to hospital administrators that (1) all
electrically powered beds, especially those featuring the automatic
"walk-away down" switch with the scissor- or guillotine-type action
in
the metal underparts, be removed from high-risk areas, such as
pediatric and psychiatric wards, and (2) if removal of such beds
from
high-risk areas is not feasible, consideration be given to
deactivating the "walk-away down" switches. In addition to these
HPB
and FDA alerts, one manufacturer alerted all known owners of its
beds
to the potential danger and informed them how to inactivate the
"walk-away down" switch.
The FDA is continuing to investigate this problem in an effort
to
prevent future injuries and deaths. Persons with information
concerning injuries due to and hazards associated with electrically
operated hospital beds should contact Mr. Joseph G. Valentino,
Product
Problem Reporting Program, U.S. Pharmacopeia, 12601 Twinbrook
Parkway,
Rockville, Maryland 20852, toll-free number (800) 638-6724.
Reference
Walshe A, Rosen H. A study of patient falls from bed. J Nurs
Admin 1979;9:31-5.
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