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; Orthopedics

Device Factors
Design / labeling error; Device failure; Improper maintenance, testing, repair, or lack or failure of incoming inspection; Manufacturing error

Document Type
Hazard Reports

External Factors
*Not stated

Mechanism of Injury or Death
Failure to deliver therapy; Mechanical (puncture, perforate, lacerate, break, cut, tear, nick, crush)

Support System Failures
Lack or failure of incoming and pre-use inspections

Tampering and/or Sabotage
*Not stated

User Errors
Failure to perform pre-use inspection; Incorrect clinical use

UMDNS
Beds, Air Fluidized [16-889]; Beds, Circle Electric [10-345]; Beds, Electric [10-347]; Beds, Flotation Therapy [10-348]; Beds, Rocking [10-363]; Frames, Turning [14-256]

Special Care Beds Require Special Attention



Hazard [Health Devices Mar 1988;17(3):101-2]

Problem

Special care beds and tables, including rocking beds (also called kinetic treatment tables), turning frames, circle beds, and air-fluidized and low-air-loss flotation therapy beds, are used in hospitals to accommodate a variety of patient needs and conditions. These beds typically have a wide range of positioning adjustments, and rocking beds (kinetic treatment tables) also actively shift the patient from side to side. In addition, accessories, such as traction equipment, must frequently be used with the beds. The stability and security of support mechanisms and fasteners are of primary importance. Consequently, special care beds are rather complex. To ensure safe and effective use of these beds, hospital personnel must be thoroughly familiar with their design features, applications, patient restraint systems, and adjustments.

Hospital beds are involved in a large percentage of patient accidents. Compared with accidents involving general care beds, injuries from accidents involving special care beds are likely to be more severe. A member hospital reported finding a comatose patient on the floor of her room. Apparently, she had fallen out of the rocking bed when it rotated to one side. Patients may have multiple fractures, spinal or cranial injuries, extensive burns, or decubitus ulcers. They may be recovering from neurosurgery or need to be completely immobilized. Even a jolt to such patients, not to mention a fall, could cause extensive injury.

Incidents involving special care beds usually result from a component failure or from user error. Member hospitals have also reported the following incidents:

  • Loosening of the knurled nut that secured the support frame in place on circle beds and turning frames caused the support frames to fall and the patients to be injured. The knurled nuts are supposed to be manually tightened. Inadequate tightening of the nut, combined with a patient's movements, may loosen it (see Health Devices 10:27, November 1981).
  • Loose set screws on kinetic treatment tables allowed a support shaft to dislodge from its collet, causing the head of the table to fall. If a patient had been on the table at the time of the fall, the patient's injuries could have been exacerbated (see Health Devices 10:174, June 1981).
  • A caster separated from the frame of a 2,000 lb air-fluidized flotation therapy bed while a patient was being moved. While caster loss is not likely to cause the bed to tip over, caster failure will cause the bed to tilt, jarring the patient and posing a hazard to personnel (see Health Devices 10:200, June 1981).
  • Collapse of the head-end assembly of an orthopedic turning frame resulted in severe tilting, causing the patient to fall to the floor. Radiologic examination immediately after the accident revealed a bone fragment in the spinal canal, requiring prompt surgical removal. The patient had been in the bed for two weeks, recovering from a broken neck (see Health Devices 11:118-9, January-February 1982).

Discussion

Compared with many other types of hospital accidents, patient injuries involving special care beds are preventable with proper equipment maintenance, personnel training, and adherence to simple procedures. The four preceding reports represent problems resulting from a combination of improper use, inadequate user training and knowledge, and failure to perform inspection and preventive maintenance procedures. Although attention to these details will not prevent all accidents, it can reduce their frequency and severity. Other types of accidents common to general care beds, such as crushing injuries and strangulation from being caught in the side rails, may also occur with some special care beds.

Because of the high cost and limited application of these beds, hospitals often rent or lease them as needed from local distributors. (This is especially true for rocking beds and flotation therapy beds.) Because the distributor is responsible for maintenance, the beds are often put into service without hospital inspection. However, damage and loosening of the fasteners can occur during delivery and installation, even if the distributor checked the beds prior to shipment. Hospitals should, therefore, always perform initial and follow-up inspections (e.g., every six months).

Personnel familiar with special care beds usually perform the initial setup and adjustments. However, other nursing and medical staff may be responsible for subsequent care of the patient and may make bed adjustments without having been properly trained. Staff turnover and the relatively infrequent use of special care beds make the problem worse. Some personnel may be intimidated by the complicated appearance of specialty beds. Thorough training is essential for safe, effective use.

Having to lie in a strange-looking specialty bed may frighten a patient. Hospital personnel can help alleviate the patient's fears by displaying confidence in their knowledge of the bed and its working condition and, when appropriate, explaining and demonstrating the bed's operation.

Recommendations

  1. Special care beds should be placed on a routine inspection and preventive maintenance schedule. Rented or leased beds should undergo incoming inspection by qualified hospital clinical engineering or maintenance personnel. The procedure and checklist for electric beds in the Health Devices Inspection and Preventive Maintenance System manual are appropriate for incoming and routine inspection of most special care beds. Follow manufacturer-recommended maintenance instructions.Special care beds should be inspected at least every six months for the following:
    • Mechanical integrity (weld cracks, loose fasteners, caster security, stripped threads)
    • Electrical integrity
    • Proper operation in all modes
  2. Ensure that all nursing personnel who will use the beds are instructed in and familiar with:
    • Adjusting the bed to the prescribed position
    • Properly setting all controls (e.g., airflow)
    • Tightening procedures for mattress lacings
    • Setting and securing all required fasteners, patient restraints, adjustment mechanisms, and mechanical stops before and after turning the patient
  3. Make available "short courses" (films, slide shows, or literature) on the use of special care beds. These should be required training for incoming personnel and those who use special care beds. The operator's manual should be readily available for reference by personnel.

UMDNS Terms

  • Beds, Air Fluidized [16-889]
  • Beds, Circle Electric [10-345]
  • Beds, Electric [10-347]
  • Beds, Flotation Therapy [10-348]
  • Beds, Rocking [10-363]
  • Frames, Turning [14-256]

Cause of Device-Related Incident

Device factors: Design/labeling error; Device failure; Improper maintenance, testing, repair, or lack or failure of incoming inspection; Manufacturing error

User errors: Failure to perform pre-use inspection; Improper clinical use

Support system failure: Lack or failure of incoming or pre-use inspections

Mechanism of Injury or Death

Failure to deliver therapy; Mechanical


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