Design, Education, and Use Causes of Entrapments in Nursing Homes

Even though entrapments happen directly when a patient becomes somehow trapped in a rail, the causes of these incidents happen far before it comes to the point of entrapment. Causes may include end-user error, communication failures, design and marketing flaws, and a failure on the part of the supplier to deliver the proper parts or education to the facility.

Although there may be various situations and occasions in which an entrapment happens, there are definite causes for entrapment that have little to nothing to do with what the patient does, or with the patient's mental or physical status. Entrapment causes can be broken down into two primary groups: design and marketing issues, and supplier or end-user error. The first group primarily involves issues that happen at the manufacture and design end. The second group involves causes resulting from errors with the medical equipment supplier or the facility and its protocol and personnel.

Design and marketing issues may include significant design flaws and promises or guarantees made during the marketing process. These design flaws can involve spaces that allow a patient head, neck, or chest to be stuck easily, yet make it very difficult for the patient to escape from the rail. These are similar to the design flaws that happen with infant cribs using outdated standards. Marketing issues can come about if the manufacturer makes claims that the rails are "gap free," or can be gap free with the use of special fillers, yet the manufacturer then makes little to now effort on how to educate the facility about proper use of these devices so the promises can be satisfied. These still are not manufacturer defects, per se. Instead, they are causes that are related to the use of the rails without an explicit deficit during the manufacturing process.

Supplier and end-user issues happen outside the realm of responsibility of the manufacturer. Instead, these causes happen either directly in the facility, or at the middle point between the manufacturer and the facility (the supplier). Supply causes can involve unawareness of problems, delivery without education, and poor training on the part of the supplier. The supplier also may be at fault for delivering improperly fitting parts of the bed system.

In a 2002 report, The Joint Commission published details about reports of entrapment deaths and injuries that it had received since 1995. There were seven reports, five of which had detailed and substantiated information available. The Joint Commission's report included information about what personnel at the facilities identified as being root causes. These root causes did not focus on manufacturing defects, and in fact did not even mention possible defects as being a problem. The most common errors happen in the end-user environment, and not in design, marketing, or supply.

The most common error The Joint Commission reported in the five cases was a breakdown in communication between personnel. This breakdown happened among staff in two cases, with or between physicians in two cases, and between administration and staff in the remaining cases. This indicates clear end-user error, as the manufacturer or supplier cannot dictate communication protocols among staff, administration, and physicians. The second most common cause was what The Joint Commission called an "equipment factor." In none of the cases, however, was the "equipment factor" a design flaw. Instead, that factor was a lack of side rail protector pads (fillers to put in the gap created by using the rails and beds), and a problem with the configuration of the bed, mattress, and bed rail.

Other factors that The Joint Commission reported also could be considered end-user problems. Those included problems with patient assessments, problems with patient observation, and other "human" factors like training of staff, use of an outside nurse, and leadership issues.

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