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Bedford VA Improves Wheelchair Safety with New Labeling System

Wheelchair Team
Wheelchair Team

BEDFORD, MA - A potentially dangerous situation uncovered in Oct 2022 sparked a major patient safety initiative at the VA Bedford Healthcare System. Staff discovered a veteran improperly leaving the facility in a wheelchair without secure tie-down brackets, putting him at risk during transportation.

This alarming incident led occupational therapy supervisor Kathleen Ross and her team to rapidly inspect every wheelchair on campus. "It was identified that a veteran was leaving for an appointment in a wheelchair unsafe for travel," Ross said. "Upon observation staff determined the veteran could not use their wheelchair, as it did not have the appropriate transit system feature."

Over the next two weeks, Ross and staff placed colored duct tape labels on all wheelchairs - red meant not transit safe, while green indicated the chair had the proper secure brackets for transport. They also immediately purchased new compliant chairs for the campus' community living center, for use if a Veteran's personal chair is not safe for travel.

"The duct tape labels were an acceptable interim safety approach, but a long-term plan was needed," Ross said. She partnered with facility sign shop team member Scott McLaughlan to create permanent wheelchair labels. As of February 2024, every wheelchair on campus now has a laminated label clearly showing if it is approved for patient transit.

This improvement came just in time. In 2021, a report found over 100 patient transport accidents nationwide involving poorly secured wheelchairs.

The innovative labeling system is now being shared as a best practice with VA facilities across New England. “Our goal is for other VA’s to learn about Bedford’s initiative to identify this important wheelchair safety feature and hopefully consider implementing it,” Ross said.

"We are proud of the fast action our team took to ensure a safety gap was addressed," said Ellen O'Neil, Chief, Sensory and Physical Rehabilitation Service. "Thanks to their commitment to Veteran care, and excellent collaboration with other services, we have a robust system in place that will prevent accidents and give our veterans freedom to access outside care safely."