June 16, 1983
Dear Hospital Administrator:
This is to alert you to a potential hazard associated with electrically powered hospital beds, and to suggest precautions you should consider to avoid accidents in the future.
Three children, ages 3, 6, and 11, have been crushed in hospital bed accidents in the past 16 months. They were caught between the stationary portion of the bed and its moving frame, following activation of automatic bed-lowering controls (“walking-away” switches). Reports alleged that the children were either playing with the controls or were curious about the beds’ mechanical operation. Note that although the two U.S. fatalities were associated with Hill-Rom Model 840 beds, it is possible that other makes and models could pose a similar or problem.
It is especially important to take measures to avoid mishaps in pediatric wards and in general care areas where patient behavior may not be predictable. We suggest the following measures:
- Since this problem may not be limited to Hill-Rom beds, consider the hazard potential of all electrically powered beds in your facility, paying special attention to those which have automatic lowering devices such as the “walk-away down” feature along with a “scissors” or “guillotine” action in the metal underparts of the bed. Consider removing those beds which could be hazardous from high risk areas such as pediatric and psychiatric wards.
- If removing such beds from high risk areas is not feasible, consider deactivating “walk-away down” type switches in those areas.
Beyond such specific steps, I believe it is equally important to raise the awareness of nurses and others responsible for patient care about the potential for accidents with electrically powered beds, so that they can better anticipate problems and act to prevent injuries.
In the meantime, we are investigating the problem further with bed manufacturers and other interested organizations. We would be most interested in your expierence regarding injuries associated with electrically powered hospital beds. Please direct this information to:
Dr. Joseph G. Valentino
Product Problem Reporting Program
The United States Pharmacopeia
12601 Twinbrook Parkway
Rockville, MD 20852
Toll Free number: 800-638-6725
You cooperation is most appreciated.
John C. Villforth
National Center for Devices and Radiological Health
Food and Drug Administration