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Prepared by the Healthcare Insurance Reciprocal of Canada (HIROC)

Patient Population

  • Adult1,2
  • Geriatric2,3
  • Paediatric5,6,7,8,9,10,13,14


  • Asphyxia associated with restraint use1,2,3,7,10,11,15
  • Asphyxia associated with bed-related entrapment5,12
  • Strangulation associated with hospital equipment5,6,8,13,14

Equipment Contributing to Injury

  • Nursing bedcover3
  • Restraint waist belt3
  • Patient bed/crib4,5,12
  • Medical lines5,6,8,9,13,14
  • Apnea monitor lead5

Conditions Contributing to Adverse Event

  • Mental illness1,7,10,11
  • Substance abuse1
  • Obesity1
  • Developmental disorders7
  • Inadequate patient assessment10,14
  • Inadequate care planning10
  • Inappropriate room or unit assignment10
  • Lack of patient observation procedures and practices3,6,10,11
  • Staff issues in training3,10,12,15
  • Inadequate staffing levels10
  • Staff competency and credentialing problems10
  • Equipment failures10,12

Recommended Mitigation Strategies


  • Revise organizational policies to prohibit the use of higher-risk forms of restraint, including: (1) any form of restraint that involves compression of the patient's chest; (2) prone restraint, (3) supine restraint, (4) any type of technique that obstructs airways or impairs breathing, (5) any technique that obstructs vision, and (6) any technique that restricts a patient's ability to communicate.11
  • Restraints should be applied strictly in accordance with policies and procedures, using an approved method, and according to the patient's behavior support plan.7,15
  • Consider age and gender in writing therapeutic hold policies.10
  • Discontinue the use of high neck vest and waist restraints.10
  • Mandate the recording and reporting of restraint.2
  • Avoid restraint use by actively promoting alternative intervention and management strategies that focus on primary and secondary intervention.2,10,15
  • Clear medical documentation of the restraint device including indication, during and method.3,11
  • Promote staff training in alternatives to physical restraint and in the proper use of holding and restraint.3,10,15
  • Engage in close monitoring of patients under restraints, with special attention to paediatric patients, as well as those who exhibit dementia or apractic disorders.3,10,11
  • When restraints have been employed, monitor vital signs (pulse, respiration, blood pressure, and oxygen saturation) to help determine how the patient is responding to the restraint.15
  • With prone restraint, ensure that the airway is unobstructed at all times and that the patient's lungs are not restricted by excessive pressure on the patient's back.10
  • With supine restraints, allow the patient's head to rotate freely. Do not cover the patient's face with a towel, bag, etc., during therapeutic holding.10

Entrapment – Beds

  • Ongoing monitoring and maintenance of bed rails.4,12
  • Consider compliance with dimensional guidelines when engaging in bed procurement decision-making.4,12
  • 'Retrofit' older bed models to eliminate gaps.4
  • Develop guidelines on avoiding bedrail entrapment gaps; the routine measurement of gaps may be a consideration for residential care settings.4
  • Ensure that bedrails are only used when appropriate; if bedrails are to be used, the appropriateness of the bed, rail and mattress combination for the patient should be considered.4,12

Entanglement and Entrapment – Medical Lines

  • Children who are at risk for entanglement should be placed under continuous observation.6,14
  • Within the paediatric setting, oral treatment or use of a heparin-locked needle should be considered in place of intravenous therapy.6,14
  • Within a paediatric setting, if intravenous tubing is used, excess amounts should be coiled to prevent entanglement.6
  • Implement a routine, standardized process that focuses on the prevention of entanglement of therapeutic tubing, cords and cables.8,14

Works Cited

  1. O'Halloran R, Frank J. Asphyxial death during prone restraint revisited: A report of 21 cases. The American Journal of Forensic Medicine and Pathology. 2000; 21(1). 39-52. [Erratum in Am J Forensic Med Pathol. 2000; 21 (2): 200.]
  2. Paterson B, Bradley P, Stark C, Saddler D, Leadbetter D, Allen D. Deaths associated with restraint use in health and social care in the UK. Journal of Psychiatric and Mental Health Nursing. 2003; 10 (1): 3-15.
  3. Karger B, Fracasso T, Pfeiffer H. Fatalities related to medical restraint devices: Asphyxia is a common finding. Forensic Science International. 2008; 178 (2-3): 178-184. doi: 10.1016/j.forsciint.2008.03.016.
  4. Haugh J, Flatharta TO, Griffin TP, O'Keeffe ST. High frequency of potential entrapment gaps in beds in an acute hospital. Age and Ageing. 2014; 43 (6): 862-865. doi: 10.1093/ageing/afu082.
  5. Warda L. Is your hospital safe for children? Applying home safety principles to the hospital setting. Paediatrics & Child Health. 2004; 9 (5): 331-334.
  6. Sullivan P. IV tubing poses strangulation hazard, hospitals warned. CMAJ. 2002; 167 (5): 529. 
  7. Nunno MA, Holden MJ, Tollar A. Learning from tragedy: A survey of child and adolescent restraint fatalities. Child Abuse & Neglect. 2006; 30 (12): 1333-1342.
  8. Haynes J, Bowers K, Young R, Sanders T, Schultz KE. Managing spaghetti syndrome in critical care with a novel device: A nursing perspective. Critical Care Nurse. 2015; 35 (6): 38-45. doi: 10.4037/ccn2015321.
  9. Janiszewski Goodin H, Ryan-Wenger NA, Mullet J. Pediatric medical line safety: The prevalence and severity of medical line entanglements. Journal of Pediatric Nursing. 2012; 27 (6): 725-733. doi: 10.1016/j.pedn.2011.08.003.
  10. Masters KJ, Bellonci C. Practice parameter for the prevention and management of aggressive behaviour in child and adolescent psychiatric institutions, with special reference to seclusion and restraint. Journal of the American Academy of Child & Adolescent Psychiatry. 2002; 41 (2 Supplement); 4S-25S.
  11. Recupero PR, Price M, Garvey KA, Daly B, Xavier SL. Restraint and seclusion in psychiatric treatment settings: Regulation, case law and risk management. Journal of the American Academy of Psychiatry and the Law. 2011; 39 (4): 465-476.
  12. Sharkey JE, Van Leuven K, Radovich P. Risks related to patient bed safety. Journal of Nursing Care Quality. 2012; 27 (4): 346-351. doi: 10.1097/NCQ.0b013e318264744b.
  13. Lunetta P, Laari M. Strangulation by intravenous tubes. The Lancet. 2005; 365 (9470): 1542.
  14. Garros D, King WJ, Brady-Fryer B, Klassen TP. Strangulation with intravenous tubing: A previously undescribed adverse advent in children. Pediatrics. 2003; 111 (6 Pt 1): e732-e734.
  15. Springer G. When and how to use restraints. American Nurse Today. 2015; 10 (1): 26-27.