Hospital Beds - Risk of Patient Entrapment — recall 56887

Reported risk: Health Canada continues to receive incidents of patient entrapment in hospital beds. Between August 2012, the date of the last Notice to Hospitals issued by Health Canada, and March 2017, 58 additional incidents of patient entrapment in hospital beds, including 11 deaths, have been reported to Health Canada. All hospital beds. Bed entrapment is defined as an event involving a patient or a resident being caught, trapped or entangled in the bed rails, mattress or bed frame of a hospital bed. Several health conditions and patient characteristics have been associated with an increased risk of patient entrapment in hospital beds. These include, but are not limited to, cognitive and communication impairments, small and frail patients, agitation, pain, uncontrolled body movements and bladder and/or bowel dysfunctions. Although limited information is available about the circumstances and factors leading to the specific cases of patient entrapment, all reported cases of death indicated the involvement of the bed rails in the entrapment. Consequently, the risk associated with the use of bed rails should be evaluated, taking into consideration the patient's health conditions. Points to consider for the patient assessment are described below. Bed system components have also been found to contribute to patient entrapment incidents. Notably, the mattress has been identified as a contributor to patient entrapment. The mattress is usually replaced before the bed frame, occasionally with an incorrect size or incompatible mattress which can create unsafe gaps. Old mattresses can also play a role in the entrapment risk. Over time the mattress can get compressed and can create unsafe openings or gaps. Incompatible bed rails or the design of some bed rails can also create hazardous spaces, thus increasing the risk of patient entrapment in hospital beds. Health Canada has previously communicated on this safety issue via: February 2015 Hospital bed safety 2 August 2012 Notice to Hospitals 3 October 2009 Notice to Hospitals 4 June 2008 fact sheet entitled Bed Rails in Hospitals, Nursing Homes and Home Health Care 5