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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

  1. Walshe A, Rosen H. A study of patient falls from bed. J Nurs Admin 1979;9:31-5.



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