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Public Safety Message from the Chief Coroner for Ontario

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Public Safety Message from the Chief Coroner for Ontario

Therapeutic air mattresses may pose entrapment risks.

Dr. Andrew McCallum, Chief Coroner for Ontario, is alerting all Ontarians to the uncommon but significant risks which may be associated with the use of therapeutic air mattresses that are currently in use in hospitals and long-term care facilities in the prevention of compression/bed sores. Therapeutic air mattresses are a component of preventive skin care (avoiding pressure ulcers) in persons who are bed-bound. They partially deflate and inflate in a programmed sequence to relieve pressure on the skin. However, our investigations have revealed that in certain, albeit uncommon circumstances, the patient can become trapped between the mattress and the bedrails or bed frame. In May 2009, an elderly patient in a long-term care facility died after becoming wedged between the air mattress and the bed frame. A coroner's investigation revealed that these air mattresses are sold without frames, therefore they are used in conjunction with other manufacturer's equipment. The coroner's investigation involved an examination of the equipment by an engineer who determined that these air mattresses should be assessed for compatibility with bed frames as gaps may be present that could pose entrapment dangers to patients, as was the case in the May 2009 death. In March 2010, the Office of the Chief Coroner issued five recommendations that were disseminated to a number of stakeholders for the purpose of educating them about the hazards associated with these air mattresses, in order to prevent similar deaths. Since that time there have been two other deaths involving entrapment between bedrails and inflatable mattresses. As a result, we are issuing this warning publicly so that both professional caregivers and loved ones of patients will be aware. It is a central tenet of enhanced patient safety that the family of loved ones play a role on the care team. By releasing these recommendations publicly, we aim to make the public more broadly aware of this risk so that action can be taken to reduce the risk. We have chosen a public safety message as we can make this information available more rapidly, rather than calling an inquest which could take months to occur. The following are the recommendations that were made in March, 2010: Recommendations All Ontario Hospitals and the Ontario Hospital Association:

  1. All hospitals in the province of Ontario should develop a policy regarding adult hospital beds, patient entrapment hazards, and safe utilization of therapeutic mattresses. This document should consider;
    • the following reference; Health Canada's Guidance Document, "Adult Hospital Beds: Patient Entrapment Hazards, Side Rail Latching reliability, and Other Hazards," effective March 17, 2008.
    • and ensure that the hospital is compliant with the Health Canada Guidance Document.
    • the potential hazards of bed entrapment, particularly where a therapeutic mattress is in use.
    • a description of the zones where entrapment is most likely to occur.
    • a summary of how zones are tested which reflects the work of the Hospital Bed Safety Workgroup (HBSW).
    All Ontario long term care facilities and the Ontario Long Term Care Association:
  2. All long term care facilities in the province of Ontario should develop a policy regarding acute care, long term care and homecare beds (whichever is utilized); patient entrapment hazards, and safe utilization of therapeutic mattresses. This document should consider;
    • the following reference; Health Canada's Guidance Document, "Adult Hospital Beds: Patient Entrapment Hazards, Side Rail Latching reliability, and Other Hazards," effective March 17, 2008.
    • and ensure that the long-term care facility is compliant with the Health Canada Guidance Document.
    • the potential hazards of bed entrapment, particularly where a therapeutic mattress is in use.
    • a description of the zones where entrapment is most likely to occur.
    • a summary of how zones are tested which reflects the work of the Hospital Bed Safety Workgroup (HBSW).
    All Ontario hospitals and long term care facilities:
  3. All hospitals and long term care facilities should develop education programs for their staff when their policy has been completed regarding adult hospital beds, patient entrapment hazards, and safe utilization of therapeutic mattresses.
  4. Distributors of therapeutic mattress systems: All distributors who provide and distribute specialized therapeutic mattress systems for patients in hospitals, long term care facilities
  5. and for home care clients should ensure that their installations of the mattress systems conform to the Health Canada Bed Safety Guidelines, "Adult Hospital Beds: Patient Entrapment Hazards, Side Rail Latching reliability, and Other Hazards."
  6. Ministry of Health and Long-term Care:
  7. The Ministry of Health and Long-Term Care, which funds the costs for such items as therapeutic mattresses through its High Intensity Needs Program should specify that institutions requesting therapeutic surfaces on behalf of clients have required that the distributor installing therapeutic mattress systems has met safety requirements as described in "Adult Hospital Beds: Patient Entrapment Hazards, Side Rail Latching reliability, and Other Hazards."
  8. Additional Resources

    Quotes

    “Awareness and education are key to prevention”

    Dr. Andrew McCallum

    Chief Coroner for Ontario

Media Contacts

  • Dr. Andrew McCallum

    Chief Coroner for Ontario

    416-314-4000

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