[104689331]
While lift team was transitioning paraplegic pt from one sizewise bed to another using a draw sheet method, first bed shifted sideways and pt fell between the beds. Lift team caught pt at her head/shoulders, but there was pt impact with the floor. Lift team states they set brakes on both beds prior to the transfer. Device was sequestered and inspected by both a hospital bmet, a hospital biomedical engineer, and a mfr service engineer. Brakes were tested, and they were found to operate as designed. No device failure found. However, the front and rear brake systems do not operate the same, so that users must push the head-end (red) brake pedal down as well as pulling the foot-end (green) brake pedal up in order for all casters to lock, regardless of caster direction. Therefore, pushing down on the foot-end brake pedal does not lock the foot-end casters until they are fixed in the forward direction (presumably for steering purposes). We believe it is very possible that the lift team pushed down on both head and foot-end brake pedals, assuming this locked all four casters, but which may have allowed the foot-end casters to move sideways during pt transfer if the casters weren't in the front fixed position. We believe that this incident was a result of poor device design and/or lack of proper brake use labeling. It is to be noted that, although this incident occurred with a sizewise evolution bed, this counter-intuitive brake design is not exclusive to this model, as we saw other sizewise models in-house with the same design.
Patient Sequence No: 1, Text Type: D, B5