Joint Commission Resources QI Online Offers Tips on Reducing Bed Entrapment Risk
MedSun: Newsletter #9, November 2006

From January 1, 1985, through January 1, 2006, the U.S. Food and Drug Administration (FDA) received 691 reports on hospital bed entrapment—including 413 deaths—from long-term care facilities, hospitals, private homes, and other settings. Individuals most vulnerable to entrapment are elderly patients and residents who are incapacitated to some degree. Risk of entrapment increases when the bed moves up and down, and when a gap is present between the mattress and headboard or footboard, common in older “legacy beds” with new mattresses.

In light of the recent release of the FDA’s final report on the risks of bedrail entrapment, QI Online responded to these questions: How do Joint Commission standards address issues related to reducing the risk of bedrail entrapment, and how can organizations maintain compliance with those standards as they relate to this safety issue?

To diminish the risk of bed entrapment, organizations should: Use FDA guidelines to conduct a risk assessment on existing beds and replacement beds to determine the risk potential from mattresses and the suitability of various bedside rail systems for their patient populations; and retain information on patient assessment and bed evaluations for patient safety committees.

The September 6, 2002, Joint Commission Sentinel Event Alert — Issue 27 - identified these strategies for reducing the risk of injuries and/or death from bed entrapment: Orient and train staff on bedrail entrapment dangers; reevaluate beds for entrapment potential; assess patients/residents for risk of entrapment, including physical, mental, behavioral, or medication impairment; provide more frequent observation of patients/residents with risk factors for entrapment; and provide information to patients/residents and/or their families on the purpose and potential dangers of bedrails, and train them according to their needs as appropriate to the care provided.

Additional Information:

September 6, 2002, Joint Commission Sentinel Event Alert

Hospital Bed System Dimensional and Assessment Guidance To Reduce Entrapment

Clinical Guidance for the Assessment and Implementation of Bed Rails

Hospital Bed Safety

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