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 side 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 applied both brakes, the wheelchair turned away from the patient toward the side 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.