In the past, healthcare workers considered bed rails a useful device to prevent patient falls from bed. While bed rails have their benefits, their use or misuse may also place patients at significant risk, resulting in death or serious injury. Entrapment is an occurrence involving a patient who is caught, trapped, or entangled in the hospital bed system, which includes the spaces in or around the bed rail, hospital bed mattress, or hospital bed frame. Entrapped body parts associated with risk for severe injury include the head, neck, and chest. Awareness of this risk must be heightened across the healthcare continuum.

As of a December 2006 publication, Pennsylvania healthcare facilities have reported through the Pennsylvania Patient Safety Reporting System more than 100 reports of hospital bed rail entrapment.

Harm

About 4% of the entrapment reports were classified as Serious Events, and about 50% of the Incidents indicated some type of injury. The remaining reports indicated either that no injury occurred or no injury was specified.  The majority of entrapments resulted in either no harm or minor injuries (i.e., abrasions, skin tears, lacerations, bruises/redness, indentations, pain/discomfort); however, all reports indicated that healthcare workers needed to extricate the patient to prevent greater harm.

The most severe injury reported had a Harm Score of F (i.e., an event occurred that contributed to or resulted in temporary harm and required initial or prolonged hospitalization). In this case, the patient required an extended hospital stay to treat a significant methicillin resistant Staphylococcus aureus (MRSA) infection of a skin tear on a leg that had been caught in a side rail.

Age

Sixty-eight percent of the entrapped patients were 70 years of age or older. However, the ages of entrapped patients reported ranged from 10 months to 99 years old. Therefore, all ages may be at risk of entrapment, particularly if other risk factors are present.  

Body Part Entrapped

Thirty-nine percent of the PA-PSRS entrapment reports did not specify the body part entrapped. Entrapment of the head and chest (associated with potential for serious injury) occurred in 9% of the reports. The most common entrapped body parts were lower extremities (25%) and upper extremities (11%). Nine percent of reports involved entrapment of more than one body part, while another 3.5% involved the hip/pelvis. The remaining 3.5% indicated that the body/torso was entrapped.

Entrapment Zone

Eighty-seven percent of the entrapments reported to PA-PSRS occurred in three zones: Zone 5 (39%), Zone 1 (26%), and  Zone 3 (22%). This pattern varies from the U.S. Food and Drug Administration's (FDA’s) data in which the majority of reported entrapments occurred in Zones 1 through 4. The Joint Commission has received sentinel event reports of entrapment that involved Zones 1,3,5, and 6. These variations may be the result of FDA’s and Joint Commission’s databases containing a greater proportion of deaths and serious injuries, while the PA-PSRS reports are predominantly near misses.

Figure 1. Bed Entrapment Zones

Bed image adapted from: U.S. Food and Drug Administration. Hospital bed system dimensional assessment guidance to reduce entrapment—guidance for industry and FDA staff [online]. 2006 Mar 10 [cited 2006 Nov 17]. Available from Internet: http://www.fda.gov/cdrh/beds/guidance/1537.html.

Excerpted from: I’m stuck and I can’t get out! Hospital bed entrapment. PA PSRS Patient Saf Advis 2006 Dec. http://patientsafety.pa.gov/ADVISORIES/Pages/200612_15.aspx.