Dear Stakeholder,
National Patient Safety Alert: Medical beds and associated equipment risk of death from entrapment or falls
We are contacting you as an organisation that may use medical beds and associated equipment. Please can you share the following information with any of your healthcare staff involved in the management and use of medical beds and associated equipment.
The Medicines and Healthcare products Regulatory Agency [1] (MHRA) has issued an NHS National Patient Safety Alert (NATPSA) [2] and published updated guidance [3] on managing and using bed rails and associated equipment including trolleys, bed rails, bed grab handles and lateral turning devices safely.
Bed rails are used extensively in hospitals, care homes, and in the patient's own home to reduce the risk of falling out of bed and injuring themselves.
The MHRA has received a number of serious reports of incidents relating to bedrails and associated equipment. Some of these incidents have caused patient harm or death due to entrapment or falls.
Most of the incidents reported have occurred in community care settings, particularly in nursing homes or the patient's own home.
Investigations into incidents of entrapment have found a number of factors including:
- lack of risk assessment
- risk assessment not being updated following a change of equipment or patient's condition
- lack of maintenance and servicing
In the case of incidents of falls, investigations have found the likely cause to be worn or broken parts which should have been replaced during regular maintenance and servicing but were not carried out or carried
out improperly.
Appropriate and adequate risk assessment, management and maintenance should be undertaken by health professionals or competent persons to ensure avoidance of these incidents.
We ask users, carers and staff with responsibility for the provision, prescription, use, maintenance and fitting of bed rails to:
- read the NATPSA alert [2] for an explanation of the identified safety issues in detail and the actions to be taken to reduce the risk of death or disability
- read the MHRA guidance Bed Rails: Management and safe use [3]. This has been updated to include learnings from incidents reported to us.
Kind regards
Patient, Public and Stakeholder Engagement Team
Communications and Engagement
Medicines and Healthcare products Regulatory Agency
10 South Colonnade, Canary Wharf, London E14 4PU
[email protected]
Links:
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[1]
https://www.gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency
[2]
https://www.gov.uk/drug-device-alerts/national-patient-safety-alert-medical-beds-trolleys-bed-rails-bed-grab-handles-and-lateral-turning-devices-risk-of-death-from-entrapment-or-falls-natpsa-slash-2023-slash-010-slash-mhra
[3] https://www.gov.uk/guidance/bed-rails-management-and-safe-use
[4] https://www.gov.uk/help/terms-conditions
Care Provider Alliance
Working together for excellence and sustainability in social care
https://careprovideralliance.org.uk/