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Modifications of Bed Systems and Use of Accessories to Reduce the Risk of Hospital-Bed Entrapment
Despite the long history of hospital-bed use, only in the past decade have bed-related patient-safety hazards, including falls and life-threatening entrapment, been discussed publicly. Entrapment is an event in which a patient is caught, trapped, or entangled in hospital-bed components, including the bed rail, mattress, or hospital-bed frame. Since 1995, the Food and Drug Administration and the Joint Commission on Accreditation of Healthcare Organizations have issued patient-safety alerts about entrapment. While new beds are being manufactured without large gaps that would allow an individual’s head, neck, or chest to become entrapped, it is incumbent upon healthcare providers, including rehabilitation nurses, to ensure the safety of older beds in use. This article describes a facility-based approach for identifying and managing risk related to hospital bed-entrapment to be used in rehabilitation settings.
All inpatients and residents in acute care, rehabilitation, assisted living, or long-term care use a hospital bed. It is estimated that there are 2.5 million hospital beds currently in use in the United States alone. Despite the long history of hospital-bed use, only in the past decade have their patient-safety hazards, including falls and life-threatening entrapment, been discussed publicly. In 1995, the Food and Drug Administration (FDA) issued a safety alert, “Entrapment Hazards with Hospital Bed Side Rails,” that reported on 102 reported events, 68 of which were fatal (Food and Drug Administration [FDA], 1995). In response to a patient close call, an entrapment alert was issued by the Veterans Health Administration in 2001 (Veterans Health Administration [VHA], 2001). In 2002, the Joint Commission on Accreditation of Healthcare Organizations issued a sentinel event alert on bed-rail-entrapment deaths (Joint Commission on Accreditation of Healthcare Organizations, [JCAHO], 2002). Entrapment is defined as an event in which a patient is caught, trapped, or entangled in the spaces in or around hospital-bed components, including the bed rail, mattress, or hospital-bed frame.
Between 1985 and 1999, 371 incidents of patients who were caught, trapped, entangled, or strangled in beds with rails were reported to the FDA (Todd, Ruhl, & Gross, 1997); 228 people died, 87 had a nonfatal injury, and 56 were not injured because staff intervened. Most of these patients were frail, elderly, or confused. The extent to which these figures accurately represent the occurrence of entrapment is difficult to determine because close calls of any type are likely to be underreported. Any voluntary reporting system, such as the FDA device-reporting system, allows for underreporting.
Seven “entrapment zones” in and around the bed rails, mattress, and other bed parts may pose a risk if the gaps are large enough for a person’s head, neck, or chest to become entrapped (Parker & Miles, 1997). These zones include spaces (1) between bars within a side rail (head entrapment), (2) under a rail between rail supports (head entrapment), (3) between the rail and mattress (neck entrapment), (4) under the rail at the end of the rail (neck entrapment), (5) between the mattress and head and footboards (neck entrapment), (6) between the end of rails and the head and foot boards (neck entrapment), and (7) between split rails. (For a pictorial representation of each zone, refer to Parker & Miles ). In an analysis of 74 bedrail-related deaths, Parker and Miles reported that 70% of victims were asphyxiated between the bedrail and the side of the mattress. The FDA data show that 83% of entrapments occurred in zones 1–4. Mattress compression may contribute to some entrapments, particularly when specialized air or water mattresses are used (Miles, 2002).
Because side rails are considered restraints if they prevent an individual from interacting with the environment (Centers for Medicare & Medicaid Services [CMS], 2002), their routine use has been questioned. Rubenstein and Robbins (1984) described the use of bed rails as an example of “defensive medicine”—a standard of practice that is based upon medical and legal consensus rather than scientific evidence (Brush & Capezuti, 2001).
Several studies conducted mainly in long-term care settings provide evidence to contest the routine use of bed rails. In a two-group, noncontrolled comparison design, Si, Neufeld, and Dunbar (1999) found that serious injuries were not associated with the removal of bed rails. Using a retrospective, pre- and posttest descriptive, Feinsod, Moore, and Levenson (1997) found that although patients in low, railless beds fell more often, they had no greater injury rates when compared with patients in high beds using half-rails or no rails. Moreover, there was no significant difference in number of falls between residents sleeping with full-length rails and those sleeping in beds with half-length rails. In this study, long-term care residents were safest from injury when full rails were not used. In a prospective pre- and posttest, Hanger, Ball, and Wood (1999) determined that an educational and policy program on bed-rail use, together with the removal of rails from beds and the reduced use of full-length rails resulted in a significant reduction in serious patient injuries—primarily head injuries. In this study, full-length bed rails were ineffective in keeping mobile and agitated older persons in bed. Finally, Hoffman, Powell-Cope, Rathvon, and Bero (2001) enacted a quality improvement program in long-term care to find alternatives to bed rails. They found that when rail usage was decreased, there was an 11% reduction in bed-related falls and a slight decrease in the frequency of injuries related to falls from bed when compared with baseline.
As noted in a report by the Agency for Healthcare Research and Quality (Agency for Healthcare Research and Quality [AHRQ], 2001), the designs for the studies on restraints are weak; therefore no final conclusions about bed-rail safety can be drawn. Additional studies on the impact of removing bed rails using strong prospective research designs are warranted. However, the AHRQ report also concluded that growing evidence suggests that physical restraints have a limited role in medical care because they limit mobility, contribute to adverse outcomes in older persons, and increase the risk of iatrogenic events. Furthermore, they concluded that restraints, including side rails, do not eliminate falls, and decreasing their use can be accomplished without a rise in fall rates.
In April 1999, the FDA, in partnership with representatives from the hospital bed industry, national healthcare organizations, patient advocacy groups, and other federal agencies, formed the Hospital Bed Safety Workgroup (HBSW). The workgroup’s goal is to improve the safety of hospital beds for patients most vulnerable to entrapment across all healthcare settings. The workgroup developed resources, including educational brochures and videos for increasing awareness among patients, families, and providers, as well as a clinical guidance document for healthcare providers. In 2003, the HBSW submitted recommendations for dimensional guidelines to the FDA that specify the appropriate size of gaps around the mattress, bed deck, and side rails. It is expected that the FDA will release a guidance document in the next year that will be used by bed manufacturers for new bed construction, and by healthcare providers in all healthcare settings, including rehabilitation, to guide the modification of existing bed systems. Despite growing evidence against routine use of bedrails, changing this embedded practice has proved difficult. Many healthcare facilities are reducing the use of bedrails (Hammond & Levine, 1999), however, administrators, clinicians, and families remain concerned that bedrail reduction may result in an increase in falls and injuries.
Solving the problem of patient chest, head, and neck entrapment because of bed frames, bed rails, and mattresses is complex and includes compliance with the dimensional criteria for bed systems; quality improvement efforts; and patient, staff, and family education. This article should help individuals in hospitals, nursing homes, home health, and other healthcare organizations, as well as distributors of medical equipment and others who are responsible for implementing hospital-bed safety programs to reduce the risk for patient entrapment when existing hospital-bed systems are used. This article focuses on a systematic process for modifying equipment and the use of accessories to reduce the size of openings that may cause entrapment in existing bed systems. These recommendations are intended to be used in conjunction with proper clinical patient assessment and intervention.
Patient safety is defined as freedom from accidental injury and error is defined as a failure to complete a planned action as intended or use of a wrong plan to achieve an aim (Committee on Quality of Health Care in America, Institute of Medicine [IOM], 2000). Errors can lead to adverse events, defined as unintentional errors that result in negative consequences for the patient, such as strangulation from bed entrapment. Figure 1 depicts the framework driving the research at the James A. Haley Veterans Administration (VA) Medical Center Patient Safety Research Center and explains why adverse events occur and what can be done to reduce their incidence and severity. Risk factors for adverse events address the underlying causes related to patients (e.g., a patient with decreased mobility after hip replacement surgery), providers (e.g., inexperienced rehabilitation nurses who work on understaffed units), technologies (e.g., hospital-bed systems in use for more than 15 years that contain large enough gaps for entrapment to occur), and organizations (e.g., leadership that blames and punishes individual healthcare providers for errors). The 7-step approach presented here for reducing entrapment risk is based upon a systems perspective of patient safety that views all errors and adverse events a result of complex interactions among circumstances, persons, and technology (see Figure 1); (Bogner, 1994; Perrow, 1984).
Safety barriers are precautionary measures or devices that intervene to prevent an active failure from progressing to an error with an unfavorable outcome, or planned interventions that target identified risk factors to reduce the likelihood of an adverse event. Flaws in a system’s safety barriers almost always can be demonstrated, however, interventions to prevent adverse events involve intentional actions to strengthen safety barriers. These interventions can be directed toward the patient, provider, technology, or organization. Provider safety defenses focus on overcoming human limitations posed by variances in memory and practice and the potential difficulties of complex processes and provider/patient communication. Technology safety defenses focus upon overcoming limitations posed by various types of equipment or the lack of proper equipment. Organizational safety defenses are aimed at changing organizational structures and processes that contribute to adverse events.
In terms of outcomes, healthcare professionals ultimately are concerned with improving quality of care by decreasing adverse events, such as bed entrapment, and resultant injuries, such as strangulation. The remainder of this article will describe one approach rehabilitation nurses can use to reduce entrapment risk through building organizational and technological safety defenses.
Modifying hospital-bed systems: Process steps
A hospital-bed safety program should include 7 steps to modify openings within existing hospital-bed systems to reduce risk of entrapment (see Figure 2). This process for modifying hospital-bed systems, as with other patient safety programs, is complex. By implementing this facilitywide approach, rehabilitation nurses can rely upon existing patient safety structures (e.g. safety committees, risk management resources, and leadership structure). Use of this approach offers an opportunity for rehabilitation nurses to provide leadership to correct patient safety hazards in a proactive manner.
Step 1: Assemble a Team and Assign Responsibility
As with other change projects within organizations, mitigation of entrapment risk is facilitated by advance preparation, inclusion of key stakeholders, and assignment of one person to assume overall responsibility. Finding creative ways to identify and include these key stakeholders will facilitate support for a hospital-bed safety program at all levels of the organization.
Depending upon the organization setting, key stakeholder groups may include the following: (1) administrators, (2) nursing and other clinical staff, (3) patients, residents, and their families, (4) engineering and environmental services staff, (5) purchasing staff, and (6) risk managers.
Administrators are key stakeholders because they set institutional policy and make decisions about resource allocation for the institution. Administrators will be concerned with the purchase costs of bed replacement or mitigation, as well as the costs avoided by preventing bed-related adverse events. Administrators may not be aware that the life of hospital beds typically is 10–15 years, and the extent to which beds in their institutions are used beyond their recommended useful life. Administrators may prefer to systematically replace a specific number of beds each year and distribute the cost over a longer period of time. Administrative assistance is needed to track the date of all bed purchases and prioritize units for mitigation or replacement.
Costs related to the use of older hospital beds could include both direct healthcare costs associated with patient and staff injury, costs related to defending lawsuits arising from bed- related injuries, and the maintenance costs of keeping older beds in service (Braun & Capezuit, 2000). No comprehensive cost analyses were found in the literature. However, Bradham et al. (2003) attempted to determine the potential cost savings if hospital beds were made safe from both entrapment and bed-related falls. In this analysis of direct healthcare expenses associated with bed-related injuries in six VA medical centers, most of which were falls from bed, Bradham et al. found that if injury had been prevented, the savings would average $2,083 per long-term care admission and $2,505 per acute care admission. Assuming an intervention that would eliminate both acute care and extended care bed-related injuries, a cost savings of $1,858,132 each year across the six hospitals could be realized. While not all of these cases could have been prevented with low beds, the data provide some cost justification for using height-adjustable or low beds to reduce injuries due to falls.
Nursing and other clinical staff. Nurses are likely to be interested in the clinical advantages and disadvantages of bed replacements and mitigation strategies. Mitigation strategies include the use of devices and accessories to reduce the likelihood of entrapment. Nurses who are brought into the purchasing decision early likely will be more satisfied than if purchases are made without their input, and they will be more motivated to use the equipment appropriately to improve patient care and outcomes. Ways to bring nurses into the decision-making process include use of equipment fairs and unit-based clinical trials of beds and bed accessories. Rehabilitation nurses’ experiences with cognitively and functionally impaired patients would be very useful in the evaluation of beds and bed accessories. As with any new equipment or accessories, proper initial training and competency evaluation for all staff who use the equipment is critical for safety, as is periodic competency assessment for complex equipment to ensure correct use over time. Vendors are likely to have training programs in place for their equipment.
Patients, residents, and families may have some of the same concerns as clinical staff, such as whether the mitigation methods are comfortable, easy to operate, and safe. Some or all of the accessories may be unfamiliar, and their advantages and disadvantages will need to be communicated to these stakeholders. This communication can be accomplished through education programs, family meetings, and printed materials. In a related hospital-bed safety project, the current authors successfully used one-on-one patient and family communication and presentations at family meetings to enlist patient and family support (Hoffman et al., 2003). The HBSW developed a nonproduct-specific brochure and a video targeting providers and families to increase their awareness about hospital bed safety (Hospital Bed Safety Workgroup, [HBSW], 2000; HBSW, 2003a).
Engineering and environmental services staff are stakeholders because they will be responsible for routine preventive maintenance and cleaning of new beds and possibly some bed accessories. They, too, can be invited to equipment fairs to evaluate products’ ease in cleaning and durability. They often can identify potential problems based upon their experience with servicing equipment.
Purchasing staff are important stakeholders because they are responsible for communicating with vendors, negotiating prices and contracts, and placing final orders. Purchasing staff should be provided with the results of clinical evaluations and recommendations by clinical staff, patients, and engineering and environmental services to weigh the benefits and disadvantages of any mitigation strategy against cost considerations. Purchasing staff usually can negotiate prices based upon volume, so they will want to purchase as many of the same type of mitigation devices as possible. They may be able to assist in developing a comprehensive bed-replacement plan for the entire institution over a period of time.
Risk managers are stakeholders in the decisions about bed systems because they are responsible for estimating costs associated with patient and staff injuries. Much like administrators and purchasing staff, risk managers are concerned with direct costs to a facility, such as worker’s compensation, healthcare costs of treating an injured patient, and lawsuits. Risk managers also address indirect costs to a facility, such as increases in insurance premiums and damage to the facility’s reputation.
Step 2: Determine High-Risk Clinical Units
The next step is to prioritize efforts for units with the highest risk. Determining the level of risk for hospital-bed entrapment on each unit can be accomplished by considering a combination of patient, environment, and monitoring factors. Because hospital-bed entrapment is a relatively rare event, it is difficult to determine its exact risk factors. Creating a risk model for entrapment would require a record of many events with complete information. Unfortunately, the largest database for entrapment is through the FDA device-reporting system, which is not suitable for developing a reliable and valid risk model because of its voluntary nature and the lack of complete information.
It has been documented that the majority of persons who sustained an entrapment were frail elderly patients with both cognitive and functional impairments (Todd, Ruhl, & Gross, 1997). For example, a person with a head injury who has cognitive impairment, such as decreased judgment about personal safety, poor problem-solving skills, and decreased reasoning ability may not be able to call for assistance if he or she becomes trapped. By the same token, a person who has had a stroke and has decreased upper limb strength may not be physically able to extricate himself or herself if trapped. Other factors to consider in a patient risk assessment include weakness, communication impairment, or spasticity. Generally, the more risk factors present, the greater the risk. Therefore, units with frail elderly patients who have cognitive and functional impairments are probably the units with the highest risk for bed entrapment. Typically, these are long-term care units or rehabilitation settings treating patients who have experienced an event requiring acute care, such as a stroke or hip fracture. Regardless of the specific cognitive or functional impairment, strategies to reduce entrapment risk are the same (see Step 5).
Entrapment risk factors related to the physical environment include patients relatively hidden from view because of obstructions on the unit, including many private rooms, which may be more difficult to monitor. In addition, units with old bed systems that contain large gaps in and around the rails, mattresses, and bed frames might be considered high-risk units. Risk factors related to patient monitoring include low staffing levels; lower staffing at night; care delivery processes that do not anticipate basic patient care needs, such as toileting, feeding, and pain management; staff with limited familiarity with specific patients; patients who are in rooms distant from a nurses’ station; and limited use of monitoring technology, such as cameras and egress alarms.
In summary, an evaluation of the patient, physical environment and patient accessibility will define high-risk units. Typically, long-term care and rehabilitation units have the highest level of risk, followed by medical/surgical units in acute care. Patients in critical care usually are at lowest risk, because while often functionally compromised, they are directly monitored and observed frequently.
Step 3: Inventory Bed Systems
The third step in assessing risk for entrapment in hospital beds is a systematic assessment of the type of bed systems used at a facility and establishing a locator system for individual beds. If multiple types of bed systems are used in a facility and if beds are not moved among patient units, an inventory of beds in use by unit, make, and model may assist in identifying the need for replacement and specific corrective actions. The purchasing department may have records containing this information; if not, then an inventory may be developed through direct observation of all beds in a facility, starting with high-risk units, and the assignment of a unique number to each bed using a bar code or other tracking system.
Step 4: Evaluate Bed Systems for Entrapment Risk
Until the FDA issues a guidance document, the dimensional requirements of the potential entrapment zones have not been specified. However, bed systems likely to pose an entrapment risk include the following:
Although it would be ideal to evaluate each bed, if a facility has many beds of the same model, with similar mattresses, an evaluation of a few beds should provide sufficient information to identify potential problems. If a facility has mixed and matched frames, mattresses, and rails, a thorough evaluation of each bed is warranted.
Currently, new hospital-bed construction is guided by the International Electrotechnical Commission (IEC) international standard for electrically operated hospital beds (International Electrotechnical Commission [IEC], 1996; 1999), which specified measurement procedures for the gap within a rail. No gaps specified in the IEC standard are observed with a mattress in place, and therefore, the standard would not apply to measuring gaps that occur during mattress compression. The VA Patient Safety Alert (2001), specified that, “the horizontal distance (gap) between the mattress and the bed rail MUST be less…than 60 mm (2-3/8 inches) when the mattress is pushed to opposite side of mattress deck,” and that the openings within a side rail should be smaller than 120 mm (4-3/4 inches). The VA alert did not specify measurement procedures. The Joint Commission alert (2002) provided general direction for the prevention of entrapment deaths, however, it did not specify measurement requirements either. According to this alert:
While devices to measure entrapment zones may be helpful in identifying risk to patient safety, JCAHO standards do not require the measurement of entrapment zones. JCAHO standards require that organizations have a patient safety program that encompasses performance improvement, environmental safety and risk management; however, the standards do not prescribe how these activities should be structured.
Step 5: Determine Mitigation Strategies and Accessory Use
Mitigation strategies and accessory use should be based upon the hospital-bed systems assessment. Any mitigation strategy or accessory to lessen entrapment risk should not increase other risks to patients or healthcare providers. Bed and mattress combinations may present differing levels of risk that may vary depending upon the functioning of the person using them. Therefore, appropriate clinical judgment should be used in selecting bed system and accessory combinations for individual patients.
Corrective actions and relatively low-cost accessories can be used to close large gaps in the entrapment zones. These accessories include the following:
Although the HBSW recognizes that there are seven potential entrapment zones, it chose to focus on the four zones that accounted for the majority of entrapments and deaths. Based upon a review of FDA reported entrapments, zones 1, 2, 3, and 4 accounted for 87% of entrapments and 87% of deaths due to entrapment (Todd, personal communication). Thus, focusing on these high-risk zones should allow facilities to prioritize and commit resources to specific mitigation strategies.
After beds have been inventoried and evaluated for large gaps, manufacturers can be asked to help fix some of the problems. Some bed manufacturers sell retrofit kits or premade inserts that snap or bolt into existing rails (see Figure 3). If retrofit kits are not available, the bed rail can be replaced with one per manufacturers’ recommendations, or the rail can be covered with an accessory that will cover the opening. A variety of drapes and shields are available (see Figure 4) for the latter purpose, however, based upon our experience, patients and staff may be more comfortable with a clear plastic or a netted drape that allows the patient to see out and staff to see the patient in bed (see Figure 5). Some types of rail bumpers and wedges also can be used to cover a bed rail and fill in a gap between the rail and mattress (see Figure 6).
If zones under a rail between rail supports, between the rail and mattress, and under the rail at the end of the rail contain large gaps, replacement with a mattress large enough to close these openings is a good option. If the facility has multiple bed frames and multiple mattresses, color-coding beds and mattresses may assist in easily matching them. Alternatively, “stuffers” or gap fillers (see Figure 7) can be used to fill in the opening between a mattress and a rail, and any loose rails may need to be tightened.
It is possible to decrease entrapment risk by minimizing the use of side rails altogether by removing them or by fixing them in the lowest position consistent with clinical needs, local practice patterns, and manufacturers’ instruction for use. Placing the foot-end rail in the lowest position or removing foot-end bed rails will reduce the risk of entrapment around those rails. Lowering or removing all bed rails will reduce the risk of entrapment in all zones around the bed rails. Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities and Home Care Settings, developed by HBSW, describes the safe lowering of rails through the use of clinical assessment and the use of accessories and alternatives for side rail use (HBSW, 2003b). This clinical guidance, appropriate for rehabilitation nurses, recommends that the process of reducing the use of bed rails should be undertaken incrementally using an individualized, systematic and documented approach. Several other authors, reporting on quality improvement projects and research studies, documented processes for safely reducing bed rail use (Feinsod, Moore, & Levenson, 1997; Hammond & Levine, 1999; Hanger, Ball, & Wood, 1999; Hoffman et al., 2003; Si, Neufeld, & Dunbar, 1999).
When side rails are lowered or removed, steps can be taken to reduce the risk of an injurious fall from bed: using height- adjustable low beds in the very low position, hip protectors, and mats next to the bed may reduce the impact of a fall; mattresses with raised edges may remind the person that the edge of the bed is near; and body pillows or bolsters can help to keep the patient centered on the mattress and away from the mattress edges (Hoffman et al., 2003).
When altering beds and rails, it is advisable to contact the bed manufacturers to determine if such alterations could void any existing warranties.
Step 6: Determine New-Bed Purchases
An integrated approach for purchasing new beds that considers the existing inventory, options for corrective actions, and quality monitors will assist in long-range planning. Bed purchases will be most successful from a cost/benefit and safety perspective when an interdisciplinary team of purchasers, engineers, managers, and rehabilitation nurses and other clinical staff work together to balance patient and environmental risk factors, patient and staff preferences, and cost.
A long-range plan for bed replacement that prioritizes the units that will benefit most from immediate new-bed purchases and plans for trials of beds by staff and patients will assist rehabilitation nurses in making the right purchasing recommendations. Height-adjustable, electric beds are the beds of choice for reducing the risk of patient injury from falls and for protecting nurses from back injuries caused by providing care for patients who are in bed (de Looze et al., 1994; Caboor et al., 2000). For facilities that purchase or lease refurbished beds, as is often the case in home care or small facilities, these beds also should meet the recommended dimensional criteria.
Mattresses pose a unique problem because they are replaced more frequently than bed frames. Therefore, new mattress purchases should be made in consideration of the frame size on which they will be used and unique characteristics of the mattresses, particularly mattress overlays and specialty mattresses (Miles, 2002).
Step 7: Implement Quality Monitoring System
Finally, quality monitoring will allow rehabilitation nurses to evaluate the entrapment corrective actions that were taken. Although entrapment is a rare event in the general population of hospital-bed users, it is not as rare an event in the most at-risk population—elderly and frail individuals with cognitive and physical impairments. Ideally, monitoring should continue on an ongoing basis to capture near-miss and entrapment events in high-risk units and to ensure that the desired effects of corrective actions are realized. Recognizing that mitigation strategies for reducing entrapment risk could affect falls and fall-related incidents, monitoring bed-related falls also is recommended. To learn from near misses and avoid future events, a monitoring tool should include bed characteristics: make, model, and type of bed; type of mattress, location in the institution, type and size of side rails (e.g., full, half, quarter length); using patient characteristics (age, cognitive and physical functioning, height, weight, recent medications); and details of event (patient activities at the time, type and severity of injury, accessories in use, exact location at rail, mattress and/or bed deck, and height of the head and or foot sections).
Summary and conclusions
Injuries and deaths resulting from hospital-bed entrapments are preventable through the modification of existing hospital-bed systems, the use of accessories to close large gaps where entrapment of the head and neck can occur, and careful attention to patient assessment and clinical intervention. This article presents a facility-based, systematic method for modifying hospital-bed systems and using accessories to make bed systems safer.
Rehabilitation nurses frequently care for patients who are most vulnerable to bedrail entrapment—those with cognitive and functional impairments. The method presented here offers rehabilitation nurses a comprehensive approach to assessing, planning, implementing, and evaluating strategies to reduce bedrail entrapments. Until all existing beds are replaced with new beds that do not contain large gaps in and around the side rails, mattress, and bed frame, it is incumbent upon those who are responsible for patient safety in healthcare facilities to be proactive in preventing entrapment. To this end, rehabilitation nurses can partner with safety professionals to reduce bed-related adverse events.
The authors wish to acknowledge the work of the HBSW upon which this manuscript is based. The FDA, in partnership with representatives from the medical bed industry, national healthcare organizations, patient advocacy groups, and other federal agencies, formed this workgroup to improve the safety of hospital beds (see http://www. fda.gov/cdrh/beds/).
The work reported here was supported by the Department of Veterans Affairs, VISN 8 Patient Safety Center and the James A. Haley VA Hospital in Tampa, FL. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
About the Authors
Gail Powell-Cope, PhD ARNP FAAN is the director of RR&D REAP on Technology to Prevent Adverse Events at the James A. Haley VAMC in Tampa, FL. Andrea S. Baptiste, MA CIE, is an ergonomist/biomechanist at the Patient Safety Research Center, James A. Haley VAMC in Tampa, FL, and Audrey Nelson, PhD RN FAAN, is the director of the Patient Safety Research Center at the James A. Haley VAMC in Tampa, FL. Address correspondence to Gail Powell-Cope, PhD ARNP, Patient Safety Research Center, 11605 N. Nebraska Avenue, James A. Haley Veterans’ Administration Medical Center, Tampa, FL 33612, or e-mail Gail.email@example.com.
Agency for Healthcare Research and Quality [AHRQ]. (2001, July). (K.G. Shojania, B.W. Duncan, K.M. McDonald, & R.M. Wachter, Eds.) Making health care safer: A critical analysis of patient safety practices. Evidence report/technology assessment No. 43 Prepared by the University of California at San Francisco–Stanford Evidence-based Practice Center under Contract No. 290-97-0013, AHRQ Publication No. 01-E058. Rockville, MD: Author.
Bogner, M.S. (1994). Introduction. In MS Bogner (Ed.). Human error in medicine (pp. 1–11). Hillsdale, NJ: Lawrence Erlbaum Associates.
Bradham, D., MacClellan, L., South, B., Tate, M., Powell-Cope, G., Luther, S. et al. (2003). Hospital bed-related adverse events, Part II: Direct costs to a VA healthcare network. Journal of Healthcare Safety, 1(3), 24–30.
Braun, J.A., & Capezuti, E. A. (2000). The legal and medical aspects of physical restraints and bed siderails and their relationship to falls and fall-related injuries in nursing homes. DePaul Journal of Health Care, 4(1), 1–72.
Brush, B., & Capezuti, E. (2001). Historical analysis of siderail use in American hospitals. Image: Journal of Nursing Scholarship, 33, 381–385.
Caboor, D., Verlinden, M., Zinzent, E., Van Roy, P., van Riel, M., & Clarys, J. (2000). Implications of an adjustable bed height during standard nursing tasks on spinal motion, perceived exertion and muscular activity. Ergonomics, 43, 1771–1780.
Center for Medicare and Medicaid Services [CMS]. (2002, October 22). Final draft of Technical Information for the Quality Measures Included in the Nursing Home Quality Initiative. Retrieved September 1, 2004, from http://tinyurl.com/5r7zh
Committee on Quality of Health Care in America, Institute of Medicine. (2000). To err is human: Building a safer health system. (L.T. Kohn, J.M. Corrigan, & M.S. Donaldson, Eds.), Washington, DC: National Academies Press.
de Looze, M.P., Zinzen, E., Caboor, D., Heyblom, P., van Bree, E., van Roy, P. et al. (1994). Effect of individually chosen bed-height adjustments on the low-back stress of nurses. Scandanavian Journal of Work Environment Health, 20(6), 427–434.
Feinsod, F. M., Moore, M., & Levenson, S. A. (1997). Eliminating full-length bed side rails from long-term care facilities. Nursing Home Medicine, 5(8), 257–263.
Food and Drug Administration [FDA], Center for Devices and Radiological Health. (1995). Safety alert: Entrapment hazards with hospital bed side rails. Retrieved September 1, 2004, from http://www.fda.gov/cdrh/ bedrails.html
Hammond, M., & Levine, J. (1999). Bedrails: Choosing the best alternatives. Geriatric Nursing, 20, 297–300.
Hanger H.C., Ball, M.C., & Wood, L.A. (1999). An analysis of falls in the hospital: Can we do without bedrails? Journal of the American Geriatrics Society, 47, 529–531.
Hoffman, S., Powell-Cope, G., Rathvon, L., & Bero, K. (2003). BedSAFE: Evaluating a program of bed safety alternatives for frail elders. Journal of Gerontological Nursing, 29(11), 34–42.
Hospital Bed Safety Workgroup [HBSW] (2000). A guide to bed safety—Bed rails in hospitals, nursing homes and home health care: The facts. Retrieved September 1, 2004, from http://tinyurl.com/3lxw2
Hospital Bed Safety Workgroup [HBSW] (2003a). Do no harm: Hospital bed safety [Video]. Order form available at http://tinyurl.com/3jtbs
Hospital Bed Safety Workgroup [HBSW] (2003b). Clinical guidance for the assessment and implementation of bed rails in hospitals, long term care facilities, and home care settings. Retrieved September 1, 2004, http://tinyurl.com/5hy3x
International Electrotechnical Commission. (1996). Medical electrical equipment—Particular requirements for the safety of electrically operated hospital beds. (International Standard 601-2-38, Part 2). Geneva, Switzerland: Author.
International Electrotechnical Commission. (1999). Medical electrical equipment—Particular requirements for the safety of electrically operated hospital beds. (International Standard 60601-2-38, Part 2, Amendment 1). Geneva, Switzerland: Author.
Joint Commission on Accreditation of Healthcare Organizations [JCAHO]. (2002, September 6). Bed rail-related entrapment death. Sentinel Event Alert: Issue 27. Retrieved September 1, 2004, from http://tinyurl.com/6al5w
Miles, S. (2002). Deaths between bedrails and air pressure mattresses. Journal of the American Geriatrics Society, 50, 1124–1125.
Parker, K., & Miles, S. (1977). Deaths caused by bedrails. American Geriatrics Society, 45, 797–802.
Perrow, C. (1984). Normal accidents: Living with high risk technologies. New York: Basic Books.
Rubenstein, L., & Robbins, A. (1984). Falls in the elderly: A clinical perspective. Geriatrics, 39(4), 67–71, 75–6, 78.
Si, M., Neufeld, R. R., & Dunbar, J. (1999). Removal of bedrails on a short-term nursing home rehabilitation unit. The Gerontologist, 39, 611–614.
Todd, J., Ruhl, C., & Gross, T. (1997). Injury and death associated with hospital bed side-rails: reports to the U.S. Food and Drug Administration from 1985 to 1995. American Journal of Public Health, 87, 1675–1677.
Veterans Health Administration (2001, July 13). Revised patient safety alert—Bed rail entrapment. Document available from the National Center for Patient Safety, 24 Frank Lloyd Wright Drive, Lobby M, PO Box 486, Ann Arbor, MI 48106-0486.