A woman went to an in-hospital rehabilitation facility to use a treadmill. While walking on the treadmill, it allegedly sped up unexpectedly, resulting in a fall.

Steps Taken:

ARCCA’s expert performed an inspection of the treadmill still in use at the facility.

The facility floor was inspected for defects, and the electrical service was checked for proper wiring and polarity.
The treadmill covers were partially disassembled to inspect the motor, wiring harness, and control wiring.
The expert performed an operational test of the treadmill.
The expert reviewed the standards surrounding the treadmill.
The expert reviewed the maintenance history and facility complaints history with regard to the incident treadmill and treadmills in general.

Final Findings:

ARCCA’s expert discovered that the treadmill worked exactly as designed and as per the owner’s manual, warnings, and instructions.  The treadmill was part of a replacement of all the treadmills in the facility just prior to the incident.


Although similar in function and design, the controls for the new machine were slightly different than the machines they replaced. The facility had full-time personnel who were supposed to instruct each patient/user on the use of the machine and actually perform hands-on training for each patient/user.  The woman who fell was not specifically trained on the differences in controls between the old and new machines, and was not monitored closely during the incident.

Based on testing, inspection, and analysis of facility videos, it was concluded that the woman inadvertently entered a speed control setup screen that was new and different from the older machine. She set the speed higher than she was accustomed to. Once the machine started speeding up, the woman was not properly instructed how to dismount and/or stop the machine. Furthermore, the woman did not properly clip the emergency pull stop onto her clothing so that the machine would stop once she was pulled away.

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