CHPSO patient safety alert—Air mattress settings change after being unplugged
November 11, 2010

A CHPSO member hospital, in analyzing the causes of pressure ulcers in its patients, noted an issue with some air mattresses that may represent a contributing factor.

The Sizewise Pulsate™ low air loss mattress replacement system is currently being used at that hospital for patients at risk for pressure ulcers or with existing pressure ulcers. The manufacturer states that the mattress combines automatic pressure adjustment, a friction and shear reducing cover, and clinician-friendly controls to create an optimal support surface for wound care treatment and prevention.However, clinicians using this treatment device should be aware that if the blower has been adjusted by the clinical staff based on patient weight or patient profile, and the blower is then unplugged or turned off, the blower automatically defaults to a standard inflation. This standard inflation may not be the same as the one set at by the clinical staff. Often, the result is a surface that is either over-inflated or under-inflated.

This notice is being sent to all recipients of the CHPSO newsletter distribution list. The hospital has notified the manufacturer.

Also note there is a supplemental alert providing further information.