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Since 1995, the Joint Commission has received reports of seven deaths or injuries related to bedrails, leading the accrediting body to issue a warning about this hazard.
Bedrail-related entrapment deaths were the subject of the most recent Sentinel Event Alert from the Joint Commission. Three of the seven reports were from hospitals, two were from long-term care facilities, one was from a behavioral health care facility, and one involved a patient receiving home care services.
The hospitals sent root-cause analyses to the Joint Commission, and that information provides guidance on how to avoid these deaths. All five hospital cases involved patients or residents who were 65 years of age or older, and all resulted in death by asphyxiation. Of the patients/residents, four were mentally or behaviorally impaired; three were at risk for falling; two had limited mobility in bed; one was on psychoactive or sedative medications; and one had a physical deformity.
The Joint Commission reports that asphyxiation was caused by one of the following: being caught between the mattress and the bedrail; being caught between the headboard and the bedrail; getting his or her head stuck in the bedrail; or being strangulated by a vest restraint between the rails. No particular bedrail configuration was implicated in these cases. The beds involved included some with upper rails only, upper and lower rails, both upper rails and one lower rail, or continuous full-length rails. However, the data indicate that none of the cases involved the use of only lower rails.
"Recognizing the limitations of the small sample of cases, certain findings were recurrent in the root-cause analyses," the Joint Commission reports. "All five organizations cited a breakdown in communication, most often among staff [two cases] or with or between physicians [two cases], as well as with administration [one case]. Four of the five organizations cited equipment factors, including side rail protector pads not being used [four cases] and problems with the bed/mattress/side rail configuration [one case]."
Other problems included patient/resident assessment (three cases), including adequacy of assessment, scope and timing of reassessment, and patient/resident observation; human factors (three cases), including staff orientation and use of an agency nurse; and leadership (one case).
Based on the analysis of those seven incidents, the Joint Commission urges providers to orient and retrain staff regarding safe bedrail use. Equipment redesign also should be considered, with emphasis on the use of bedrail protector pads, re-evaluation of beds for entrapment potential, replacing beds, replacing or modifying side rails with gaps greater than five inches, removing side rails from the bed, installing a positioning bar, or using lower beds.
Hospitals can redesign processes to reduce the risk, taking steps such as patient assessment for risk of entrapment (including confusion, sedation, restlessness, lack of muscle control, size), patient observation, resident/family education about bed rails, and improving communication policies.
Based on the information from the seven incidents, the Joint Commission recommends these safety precautions be implemented immediately: