In general, manufacturers intend their bed rails to be used to prevent or reduce the risk of bed occupants falling and sustaining injury. ‘Never Events’ footnote 1 are ”serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers”. This guidance should also be followed in acute settings where bed rails are used with trolleys, stretchers and emergency department beds, particularly if the patient is unattended.Ĭhest or neck entrapment in bed rails is listed (number 11) as a ‘Never Event’ according to the NHS in 2018. We have also received reports of entrapment in hospitals (acute settings) with side rails on trolleys and stretchers. Healthcare professionals or competent persons should carefully consider the benefits and risks of bed rails before they are used for a patient. Adequate and appropriate risk management should be carried out to prevent the occurrence of such incidents. Most incidents occurred in community care settings, particularly in nursing homes or the patient’s own home. The most serious of these have led to injury due to falls and death by asphyxiation as a result of entrapment of the head, neck or chest.įrom 1 January 2018 to 31 December 2022, we received 18 reports of deaths related to bed rails and associated equipment, and 54 reports of serious injuries. For the purpose of this document the term bed rail will be adopted, although other names are often used, for example, bed side rails, side rails, cot sides, and safety sidesĪt the MHRA we continue to receive reports of adverse incidents involving these devices. Introductionīed rails are used extensively in hospitals, care homes and people’s own homes to reduce the risk of bed occupants falling out of bed and injuring themselves. This document is not intended to replace clinical decision making.
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