Cause of Device-Related Incident
Device factors; Support system failures; User errors

Clinical Specialty or Hospital Department
CCU / ICU / NICU; Clinical/Biomedical Engineering; Facilities Engineering; Nursing; Pediatrics

Device Factors
Design / labeling error

Document Type
Hazard Reports

External Factors
*Not stated

Mechanism of Injury or Death
Mechanical (puncture, perforate, lacerate, break, cut, tear, nick, crush); Suffocation

Support System Failures
Error in hospital policy; Poor prepurchase evaluation

Tampering and/or Sabotage
*Not stated

User Errors
Incorrect clinical use

UMDNS
Beds, Electric [10-347]

Electric Beds Can Kill Children



Hazard [Health Devices Mar-Apr 1987;16(3-4):109-10]

Problem

A five-year-old male patient was fatally crushed beneath the pedestal-style electric bed in which he was placed upon admission to the hospital. In this case, the accident apparently occurred when the boy was playing with or accidentally operated the bed's walk-away down control, which causes the bed to continue to descend even after the control switch is released. It was reported that the hospital placed the child in an adult bed in an adult area because the pediatric ward was full. It was also reported that the hospital had established policies and procedures for use of electric beds with pediatric patients.

The impact of the three previous pediatric crushing deaths on the general health care community (particularly nursing, administrative, and engineering personnel) appears to have waned since the last death in April 1983, and the level of awareness has decreased. Because of these three deaths, ECRI recommended eliminating the walk-away down control on pedestal-style electric beds in pediatric areas. (See Health Devices 1983; 12(Jun):203-7; Health Devices Alerts Abstracts 1983; 7(Aug 5): Accession No. 06769; and "Electric beds and the pediatric patient," Hospital Risk Control 1986:2.5.1.) We believed that the three deaths demonstrated a specific hazard confined to pedestal-style electric beds equipped with the walk-away down feature used with or near pediatric patients. Thus, we recommended, with a few exceptions, that the walk-away down feature be eliminated from only those pedestal-style beds used for pediatric patients. At that time, we also recommended not placing preschoolers (i.e., patients under six years old) in electric beds, labeling beds with disabled walk-away down controls suitable for older pediatric patients, keeping the beds in their lowest position at all times, and using the lockout switch on the nurse control panel to disable the bed-height control when not in use.

Limited bed modifications, combined with well-established policies and procedures, appear to be inadequate to prevent pediatric crushing accidents in hospitals. We therefore now recommend that the walk-away down control be disabled on all pedestal-style electric beds in all areas of the hospital. This recommendation does not apply to four-poster beds (which do not present a crushing hazard) or to pedestal-style beds that are equipped with a "child-proof" walk-away down control listed by Underwriters Laboratories (UL) see UL 544, Section 23C.4, which went into effect in December 1985).

We do not recommend eliminating the walk-away down control on pedestal-style electric beds without some reservations. Initially, we believed that eliminating the walk-away down control outside of the pediatric area would result in increased injuries and deaths to adult patients from bedside falls associated with unlowered beds. This may indeed be the case; however, no data is available to support this position the height of a bed is not typically reported on incident reports of falls. The argument may have had greater validity in the past when nursing policies for keeping beds in their lowest position were lax. This does not appear to be the case today, based on a 1984 study we reviewed on bed height funded by one of the major electric bed manufacturers. Although unpublished, the results of this study deserve consideration: Of over 2,000 occupied beds in 78 hospitals, the vast majority (92%) were found in their lowest position, and bed height was unaffected by the type of control (i.e., walk-away down vs. momentary contact).

Recommendations

The death of a fourth child from crushing injuries sustained beneath a pedestal-style electric bed equipped with the walk-away down feature strongly suggests the need to totally eliminate this feature on pedestal-style beds currently in use throughout the hospital. This recommendation does not apply to four-poster beds or to recently produced beds with walk-away down controls that meet the requirements for protection against tampering set forth in UL 544, Section 23C.4. For newer beds, contact the manufacturer to determine whether the beds meet the new UL requirements. If they do not, modify them as described below. Following these recommendations will also help to ensure that you meet the latest Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements for accreditation related to the use of electric beds with pediatric patients.

  1. Disable the walk-away down feature of the bed-lowering control on all pedestal-style electric beds, except those with UL-listed controls. This applies to all areas of the hospital. Check with your bed manufacturer to determine the modification procedure (which, in most cases, is easy to carry out). The walk-away down feature on four-poster beds does not need to be disabled.
  2. Do not place preschoolers (i.e., patients under six years old) in electric beds; instead, use manual beds or cribs based on individual need or in keeping with existing hospital policy. Electric beds are acceptable for children six years old and older provided they are the four-poster type or pedestal-style beds with momentary (not walk-away down) controls.
  3. Adjust all beds (manual and electric) in all hospital areas to their lowest position at all times, except when this conflicts with other clinical needs. Establish this as a formal written nursing policy, and emphasize it in safety seminars to encourage strict adherence.
  4. Hospital housekeeping policies frequently dictate that unoccupied beds be left in a high position after linens are changed to discourage visitors from sitting on them. Instruct housekeeping and nursing personnel to discontinue this practice in pediatric wards and in rooms containing pediatric patients and instead to raise the siderails on unoccupied beds.
  5. Using the lockout switch on the nurse control panel, lock out the control for bed-height adjustment on all beds (including unoccupied ones), except when the control is being used by hospital personnel. This practice should be adopted as a formal nursing policy.
  6. We do not recommend unplugging the beds in pediatric areas as "an additional safety measure," which is a policy in some hospitals. This practice is extremely inconvenient for the nursing staff and may present a physical strain to personnel if the bed has to be pulled away from a wall and plugged in for each adjustment. In addition, emergency treatment may be delayed if the bed's position must be changed prior to administering therapy, and the likelihood of damage to the plug and cord (e.g., being crushed while lying on the floor) may be increased.

UMDNS Term

Beds, Electric [10-347]

Cause of Device-Related Incident

Device factor: Design/labeling error

User error: Incorrect clinical use

Support system failures: Error in hospital policy; Poor prepurchase evaluation

Mechanism of Injury or Death

Mechnical; Suffocation


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