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The safe use of ultra low beds | Signal

Reference number
Issue date14 February 2011

This Signal is about using ultra low beds safely and appropriately.

A sample incident reads:

“Patient has rolled off High/Low bed with crash mat in place and bed at lowest height. Banged his head on the bottom corner of the locker. Cut to right of head bleeding profusely .Wound covered by dressing pads with pressure to staunch flow……..”

Ultra low beds can help to prevent harm from falls - particularly for patients with delirium who are at risk of falling out of bed, but who cannot be given bedrails as they might try to climb over them (see NPSA bedrail guidance). However, ultra low beds need to be used safely and appropriately.

A search of the National Reporting and Learning System (NRLS) database of all incidents reported from 1 November 2003 to 24 June 2010 identified a series of patient safety incidents related to the use of ultra low beds. These included:

• injuries from floor-level furniture or fittings such as radiators, pipes, or lockers (including one serious burn);
• ultra low beds placed close to a wall but not flush with it, creating potential for asphyxial entrapment if the patient slipped between the side of the mattress and the wall (see MHRA bedrail guidance);
• ultra low beds left at working height in error, leading to falls from height
• patients who appeared to have tripped over crash mats used beside the ultra low bed (including three fractured hips).

Some reports suggested ultra low beds were seen as a universal falls prevention solution and were therefore provided inappropriately for mobile patients (see RCN restraint guidance). Additionally, some reports suggested that ultra low beds had been used with bedrails raised, negating their purpose.

It is important to note that even when ultra low beds were used correctly in the lowest position, some patients still sustained serious injuries. These included fractured hip and intracranial injury. As a result, it is important that even falls from ultra low beds are taken seriously (see the Rapid Response Report, Essential care after an inpatient fall).

Local guidance, training and specialist advice should be provided to help staff to use ultra low beds as safely and appropriately as possible.

Please contact us with your initiatives to reduce risks in these areas.

Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.