Cause of Device-Related Incident
Device factors

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)

Support System Failures
*Not stated

Tampering and/or Sabotage
*Not stated

User Errors
*Not stated

Beds, Pediatric [10-362]

Children Can Be Trapped in or Fall from Cribs

Hazard [Health Devices Jul-Aug 1989;18(7-8):287-8]


A member hospital reported that a 14-month-old child was found trapped between the raised head section and head rails of a canopy-style crib. The child was cyanotic but recovered without medical intervention. Another incident in which a child crawled through the opening of similar crib was reported through the U.S. Food and Drug Administration (FDA) Device Experience Network in 1983. The child was caught before he fell to the floor.

Although this report was related to certain brands of cribs with gatch springs, other manufacturers' models may also be involved. Cribs whose head or knee sections can be raised are likely to create a hazard because the openings between the mattress springs and head and foot rails become larger as the end sections are raised.


In the incident reported to ECRI, the head section of the mattress was raised 30°, and the opening (about 4 inches) was not wide enough for the child to fall completely through. A nurse passing by the room noticed that the child was not in his crib, investigated, and found him suspended by his head with his chin caught on the edge of the mattress. Apparently, the child's body slid through the opening in the corner of the crib, and his head lodged between the mattress and head rails.

The supplier of the incident crib models developed modifications for its cribs with gatch springs, consisting of a bedspring extender that automatically extends beyond the head section as the mattress is raised and a safety plate that will be installed below the mattress frame at the foot of the crib. These modifications should eliminate the opening at the head section of the crib and provide enough support for a child who has crawled through the foot section to stand. The supplier also recommends that mattresses of adequate size be used in the cribs.


  1. With the mattress both flat and raised, examine the spaces between the mattress springs and head, foot, and side rails of all cribs in service. If the opening exceeds 4 inches, follow the recommendations below. Also examine the spacing between crib railings of all cribs in service. If a crib has railing spaces that exceed 2-3/8 inches, remove it from service. (The Consumer Product Safety Commission (CPSC) regulation "Requirements for Full-Size Baby Cribs" [Title 16, Part 1508] recommends that spaces between crib railings not exceed 2-3/8 inches [6 cm].)
  2. Inspect your crib mattresses to determine whether they are of adequate size. The CPSC regulation for full-sized cribs in home use can be used as a guideline; it recommends that mattress dimensions be no less than ¾ in (2 cm) of the crib dimensions.
  3. Follow these interim steps for any manufacturer's crib that presents the risk of entrapment or falling; these steps allow positioning of patients who need to be inclined because of respiratory or digestive difficulties or allow older children to sit up while eating, reading, or talking with visitors:
    • Position the mattress flat, and, if possible, remove the crank. Because the crank on some cribs cannot be easily removed, label the crib above the crank with a warning that the mattress should not be adjusted.
    • When the child's head or knees must be raised, keep the mattress flat and use wedge-shaped patient positioners in the crib. Such positioning devices should fit the width of the crib.
    • Do not use ordinary pillows to position the child—the child may suffocate.
  4. If you have experienced a similar incident in which a child has become trapped or has fallen, or if the spacing between the mattress springs and head, foot, or side rails in any other manufacturers' cribs in your hospital exceeds 4² , follow the above recommendations and contact ECRI.


Beds, Pediatric [10-362]

Cause of Device-Related Incident

Device factor: Design/labeling error

Mechanism of Injury or Death


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