Fall during a wheelchair transfer - A case of mismatched brakes

We report the case of a patient who had a transtibial amputation and whose wheelchair had been inadvertently fitted with a push-to-lock brake on one s ide and a pull-to-lock brake on the other. During a standing-pivot transfer from bed to wheelchair, during which the patient thought that she had appl ied both brakes, the wheelchair turned away from the patient toward the sid e of the unlocked brake and the patient fell to the floor. This case report has implications for wheelchair design, wheelchair system management, and for user training.