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Deaths between bedrails and air pressure mattresses
1Center for Bioethics, Department of Medicine, University of Minnesota, 504 Boynton Hall, 410 Church Street, Minneapolis, MN 55455, USA. miles001@umn.edu
Objectives:
To describe how patients die by becoming trapped between therapeutic air pressure mattresses and bed rails.
Design:
A retrospective review of all voluntary reports deaths in beds with air mattresses that can be found in the Food and Drug Administration's on-line databases of adverse medical events that cover 1994 to 2001.
Setting:
Death reports come from manufacturers, medical staff, and coroners and describe deaths in hospitals, nursing homes, and home care, although type of care site is often not given.
Measurements:
Event descriptions were reviewed to determine how the person became entrapped in the rail and how responsibility for the event was allocated.
Results:
There were 35 deaths involving many product lines. Twenty-one deaths involved overlay air mattresses placed on top of a regular mattress. Thirteen patients died in beds with built-in air mattresses. Compression of the mattress allowed an off-center person to slide against the rail where reexpansion of the mattress kept the person compressed against the rail. Two patterns were seen. In one, the mattress bunched up behind a person who was lying on the side of the bed, pushing the neck against a bedrail. In the second type, a patient died after sliding off the bed and having the neck or chest compressed between the rail and bed. Manufacturers attributed the deaths to poor clinical decision-making or inadequate monitoring.
Conclusions:
Lethal asphyxiation in beds with air pressure mattresses is a variant of bedrail-mattress entrapment that requires redesign by bed manufacturers and risk awareness by clinicians.