![]() To prevent inappropriate or unintended restraint through the use of bedrails, there must be a robust assessment of whether the use of the bed rail will prevent the person from moving freely or make the person feel restricted from moving freely. Erratic, repetitive or violent movements may also cause the bed rails to break, leading to an increased risk of falling or injury from the broken rail. In some cases, the patient may attempt to climb over the bed rail, leading to the potential to fall from a height. Use of bed rails in these ways can increase the risk of falling. In addition, they are not intended to restrain people whose condition disposes them to erratic, repetitive or violent movement. They are not designed or intended to limit the freedom of people by preventing them from intentionally leaving their beds. 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. re-assessing the changing care needs of the bed occupant.correct fitting and positioning of the bed rails initially and after each period of use.taking into account the use environment and possible interaction with any other equipment, accessories or devices present in that environment as part of the risk assessment.checking compatibility of the bed rail, bed, mattress and the needs of the bed occupant.the need for good communication between bed occupant and carers or staff.assessing if a bed rail is necessary and appropriate.It also identifies areas of good practice, such as: This document identifies areas for safe practices, so that policies and procedures can be reviewed and put in place. those responsible for purchasing beds and bed rails.community equipment stores (CES) and loan store managers.carers in the community and care-at-home staff.Medical Device Safety Officers (MDSOs) for onward distribution.This document is aimed at all users, carers and staff with responsibility for the provision, prescription, use, maintenance and fitting of bed rails. For more detail on this see the implementation update on work towards a strengthened future medical devices regime. The government has extended acceptance of CE marked devices in Great Britain. This publication has been updated to reflect changes in devices and practices, as well as information gained from the investigation of adverse incidents. This document aims to set out best practice in the provision, prescription, use, maintenance and fitting of bed rails. These incidents are concerning as some have led to patient harm or death, primarily from entrapment. The MHRA is the regulator of medicines, medical devices and blood components for transfusion in the UK, a role which includes overseeing investigations into adverse events and promoting the safe use of devices in the UK.Īt the MHRA we continue to receive reports of incidents relating to bed rails and associated equipment. You can download a PDF version of Safe use of bed rails ( PDF, 562 KB, 32 pages). It replaces previous guidance on the same topic. This web page features the most up-to-date guidance.
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