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

Clinical Specialty or Hospital Department
Facilities Engineering; Nursing; Psychiatry

Device Factors
*Not stated

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
Use of inappropriate devices

Tampering and/or Sabotage
*Not stated

User Errors
Incorrect clinical use

UMDNS
Beds, Electric [10-347]

Electric Beds: Do Not Use in Psychiatric Wards



Hazard [Health Devices Dec 1991;20(12):495-6]

Problem

We investigated an incident in which a schizophrenic patient in a psychiatric hospital was found crushed to death beneath his pedestal-style electric bed. His head and neck were crushed within the frame of the bed, which was equipped with a functioning walk-away down control. We believe that the use of electric beds in psychiatric wards is unnecessary and hazardous, and we recommend discontinuing this practice.

Discussion

With all electric beds, the motorized functions for the back and knee sections, as well as for the adjustable bed height, provide a means of self-injury, especially in psychiatric locations. Although virtually all electric beds have lockout switches to disable patient side-rail or pendant controls, these can be easily defeated by ambulatory patients.

We know of no standards pertaining specifically to the use of electric beds in psychiatric wards. However, most psychiatric facilities do have their own guidelines restricting the possession and use of electric appliances with power cords. In addition to the hazards that electrically powered devices pose, suicidal patients can use the cords to hang themselves and, perhaps, to hurt others.

ECRI has previously published many articles on the hazards presented by electric beds in pediatric wards and the risks of the walk-away down feature (see Health Devices 18[9]:323-5, Sep 1989; 16[3-4]:109-10, Mar-Apr 1987; 15[11]:299-316, Nov 1986; 12[8]:203-7, Jun 1983; and 11[11]:302, Sep 1982). In this context, we also previously noted that a four-poster bed equipped with a walk-away down control is safe; however, we do not believe that this is true within the psychiatric ward.

We do recognize a possible need for a limited number of electric beds in acute intensive care units within psychiatric hospitals or psychiatric wards where patients are not ambulatory. Such patients would be constantly monitored, making the convenience and therapeutic benefit of the electrically adjustable bed features justifiable. Nevertheless, few general-care psychiatric patients require an electric bed for their stay. Unless a psychiatric patient is also being treated for an acute medical or surgical condition, using electric beds is unnecessary and dangerous.

Recommendations

  1. Do not use electric beds in psychiatric wards.
  2. If you are currently using electric beds in psychiatric wards, replace them. Alternatively, place the bed in its flat, lowest position and remove the line cord. Also be sure to remove any IV poles that may be stored within the bed frame.
  3. In psychiatric intensive care units where electric beds are deemed necessary, use the nursing controls to lock out the patient controls at all times, except when the bed is being adjusted by a healthcare provider. Also ensure that the patient is constantly monitored.

UMDNS Term

Beds, Electric [10-347]

Cause of Device-Related Incident

User error: Incorrect clinical use

Support system failure: Use of inappropriate devices

Mechanism of Injury or Death

Mechanical; Suffocation


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