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Publication Type: Medical Safety Information
Single or Multiple Incident: Multiple
Date: 2/1/2019 12:00:00 AM
Country: Japan
This alert addresses the patient safety incidents that can occur when transferring a patient from a wheelchair to a standing position. 18 cases were reported in which a patient was injured when their leg came into contact with a wheelchair footrest. Patients with fragile skin are at greater risk of suffering skin damage. Two incidents are described. In the first, a patient with fragile skin due to treatment with a glucocorticoid and suffering anasarca, was being transferred to a bed when the hem of the patient’s pants lifted and the footrest came in direct contact with the patient’s leg. The skin was torn, exposing a patch of fascia requiring 18 sutures. Similar circumstances occurred in the second incident when a patient was being transferred from a wheelchair to the bed. Seven sutures were required to close the wound to the patient’s leg. The alert provides recommendations to prevent similar incidents.

Additional Details

Device:
wheelchair, wheelchair footrest
Medication/Gas/Fluid:
glucocorticoid, predonine, prednisone

Environment / Equipment
  1. Place covers on footrests.
Rules / Policies / Procedures
  1. Ascertain the patient’s condition, then consider how to assist them and how many people should assist.
  2. When transferring patients with fragile skin, have them wear pants or socks, etc. to protect their legs.

Injury from a Wheelchair Footrest