While bed rails were essentially banned from post-acute care settings, they were still used for fall prevention in hospitals. This research provided the evidence of increased severity of injuries when patients fall from bed at higher bed heights – i.e. Researchers and clinicians set out to test the protective properties of changing bed height and floor mat use on reducing severity of injuries when patients fall from bed (Bowers, Lloyd, Lee, Powell-Cope & Baptiste, 2008). Some of you will remember this guidance, available hereįurther research was conducted by the Department of Veteran Affairs VISN 8 Patient Safety Center’s Safe Bed Program to examine risk of serious injuries from bed, because floor mat use was being recommended without evidence. Capezuti, while confirming that bed rails were unsafe, did provide recommendations for hospital and nursing home staff to protect patients in two categories: equipment (i.e., low position beds, floor mats, hip protectors), and nursing interventions (i.e., teaching patients about safe bed exits, clear signage, individualized patient care). CMS followed and developed new interpretive guidelines for surveyors of nursing homes. These dangers included patients being entrapped in the gap between side rails and bed mattresses, and injuries when patients fall with raised side rails.Īs a result, side rail use was challenged, questioned, and stopped. In 2002, research was published that exposed the dangers of hospital and nursing home bed rails that was cited by the then JCAHO - a sentinel alert about bed-rail entrapment. They created the first Guide for Modifying Bed Systems, which expanded to full scale program evaluation systems, bed purchasing guidance, and quality monitoring programs released in 2006, updated in 2017. Their goal was to provide guidance specific to improving the safety of hospital beds for patients in all healthcare settings who are most vulnerable for entrapment. Members of my VISN 8 Patient Safety Center participated. In April 1999, after the release of the bed entrapment sentinel alert, the FDA convened the first national Hospital Bed Safety Workgroup comprised of federal agencies, healthcare organizations, and patient advocacy groups. But first, let’s reflect on evidence that impacted bed rail use in healthcare settings. A Hospital Bed Safety Workgroup of 26 organizations participated in the development of this guidance. This guidance should help all organizations to evaluate policies and procedures specific to safe bedrail use. I share this brochure with you, in hopes that you will share this widely, because this brochure should inform all providers, administrators, and quality administrators about the balance of benefits versus risks when using bed rails. In 2017, the US Food & Drug Administration (FDA) provided a national guidance brochure on bed rail use in hospitals, nursing homes, and home health care - yes, across the continuum of care. Of interest, every couple of months, I receive a question about use of side rails - bed safety rails related to fall-prevention in differing settings of care. My commitment has been and will always be to help you as much as I can. I am always delighted to receive questions about fall prevention practices, resources, and even opinions.

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