Download UHN Patient Restraints Minimization

University Health Network
Policy & Procedure Manual
Clinical – Patient Restraints Minimization
Policy
In compliance with the Patient Restraints Minimization Act 2001 (PRMA, 2001),
University Health Network (UHN) minimizes the use of restraints on patients.
Restraints are used only after all appropriate alternatives have been considered and/or
exhausted.
The least restrictive restraint is selected and used for the shortest period of time.
Restraints are used only for the purposes of:
•
Preventing serious bodily harm by a patient to himself or herself or to others.
•
Enhancing the patient’s freedom with the knowledge that all measures of
restraint are for protective purposes and are only used when:
a.
A health care team assessment and analysis of the patient’s behaviour
has been completed. (In emergent situations, a thorough analysis may
not be practical until the crisis is under control.)
b.
The patient or Substitute Decision-Maker (SDM) has consented. (In
emergent situations, consent is to be obtained within 4 hours of restraint
initiation.)
c.
A doctor’s order or medical directive has been obtained. (In emergent
situations, an order may be obtained within 4 hours after the application of
restraints.)
d.
The implementation of restraints and corresponding reasoning for such
implementation has been documented in the patient health record.
A physician must give/execute an order to restrain a patient in a hospital or to use a
monitoring device with respect to a patient. The order to restrain must comply with the
Patient’s Restraint Minimization Act, 2001 (PRMA, 2001) and the UHN restraint policy.
A UHN Registered Nurse (RN) who has completed the restraints minimization education
may write an order for the application of mechanical restraints under Medical Directive
MDGEN002 – Initiation of Mechanical Restraints. Before writing the order, the RN must
review and understand Medical Directive MDGEN002 and Medical Directives
policy 3.10.022.
This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by
any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without
permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number
Section
Issued By
Approved By
3.30.007
Safety & Special Needs
Fall Safety & Restraints Committee
Nursing & Allied Health Executive
Committee; Medical Advisory Committee;
UHN Operations Committee
Original Date
Revision Date(s)
Review Date
Page
06/93
03/96; 08/01; 07/02; 01/04; 05/05
1 of 12
Restraining all four limbs simultaneously is an extraordinary measure and is used only
when all other measures of less restraint have been considered and/or exhausted and
deemed to be ineffective (not practical). The implementation of extraordinary measures
of restraint must be accompanied by constant observation.
If Security Services staff is directed to apply restraints in an emergent situation, a
member of the health care team must be present during the application of the restraint.
Commercially manufactured restraints must be used as intended by the manufacturer
and are not to be modified or adapted in any way. Staff must refer to the manufacturer
information, including the application procedures for specific types and brands of
restraint.
Approved Mechanical Restraints
The following restraint devices are approved for use at UHN:
•
•
•
•
•
•
•
•
•
•
•
Posey Freedom Splint
Posey Peek-a-Boo Mitt
Posey Quick Release Limb Holder
Posey Twice-as-Tough Quick Release Cuff
Posey Roll Belt
Posey Soft Belt (seatbelt)
Posey IV Access Jacket
Geri chair with lap tray
Hard leather limb restraints (Psychiatric Units only)
Lock and key restraints (e.g., Pinels for patients detained under the Mental
Health Act) (Psychiatric Units only)
Patient monitoring device (See Wandering Patient policy 3.30.017.)
In cases of extreme violence where Police and/or Security involvement is required,
Police and/or Security Officers may apply handcuffs.
All bed rails up is not an approved restraint at UHN. All bed rails may be raised if
used:
•
•
•
•
•
as a position device or mobility aid, e.g., to help turning
at the request of the patient
on stretchers or other transferring equipment
in treatment rooms
following medical treatment as approved practice (e.g., administration of a
sedative)
This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by
any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without
permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number
Section
Issued By
Approved By
3.30.007
Safety & Special Needs
Fall Safety & Restraints Committee
Nursing & Allied Health Executive
Committee; Medical Advisory Committee;
UHN Operations Committee
Original Date
Revision Date(s)
Review Date
Page
06/93
03/96; 08/01; 07/02; 01/04; 05/05
2 of 12
•
for a patient who is not functionally capable of voluntary movement, e.g.,
comatose, spinal cord injury, etc.
Education
Unit Managers/Clinical Educators and other members of the health care team provide
orientation to new staff and ongoing education to current staff regarding:
•
•
•
•
•
assessing patients for need for restraints
alternatives to restraints
implementation of the patient restraint minimization policy and procedure
approved restraints and their proper application (see Patient Restraints on the
UHN Nursing web site)
Code White response
UHN is committed to providing education and support to the patient to be restrained
and/or to his or her family/SDM.
Quality Reporting
Quality reporting of restraint prevalence, adverse outcomes due to restraints and
workload related to restraints is an expectation.
The UHN Fall Safety and Restraints Committee:
•
Conducts periodic prevalence audits for reporting and quality improvement
purposes.
•
Receives, tabulates, reviews and reports the results of the unit audits.
Definitions
Restrain – To restrict freedom of movement or normal access to one’s body through the
application of any physical or mechanical device, material or equipment attached or
adjacent to a person’s body that the individual cannot remove easily.
Mechanical Restraint – A mechanical device used to involuntarily restrain the
movement of the whole or a portion of a patient’s body as a means of controlling his/her
physical activities.
Chemical Restraint – A psychopharmacologic drug used for the purpose of controlling,
inhibiting, or restricting a patient’s behaviour. It is not required to treat medical
symptoms.
This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by
any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without
permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number
Section
Issued By
Approved By
3.30.007
Safety & Special Needs
Fall Safety & Restraints Committee
Nursing & Allied Health Executive
Committee; Medical Advisory Committee;
UHN Operations Committee
Original Date
Revision Date(s)
Review Date
Page
06/93
03/96; 08/01; 07/02; 01/04; 05/05
3 of 12
Environmental Restraint – Any barrier or device that limits the locomotion of an
individual, and thereby confines an individual to a specific geographic area or location.
For example:
•
•
geri chair used to confine patient movement is a restraint
arm boards for intravenous administration, stretcher straps, self-releasing
buckles for transportation are not restraints
Levels of Observation
•
Constant Observation – Continuous, one-on-one observation of patients who
are at high risk of harm to self or others. Nurse Manager/delegate
authorization is required.
Note: A sitter who is not a nurse remains with the designated patient to
observe only, and alerts the nursing staff whenever she/he observes the
patient attempting to get out of bed, remove IV line/NG tube, etc.
•
Close Observation – Checking specific patients and the environment q30
minutes.
•
Psychiatric Observation – For patients detained under the Mental Health Act
and located on units other than Psychiatry, use the psychiatric levels of
observation found on the UHN Psychiatry web site at
http://intranet.uhn.ca/departments/psychiatry/index.asp.
Health Care Team – The group that may consist of Physicians, Registered Nurses,
Registered Practical Nurses, Patient Care Assistants, and/or members of the Allied
Health Team who are trained in restraint application and involved in the delivery of the
patient’s care.
Substitute Decision-Maker (SDM) – The person who is authorized to give or refuse
consent to a treatment on behalf of a patient who is incapable with respect to the
treatment. The SDM may be a guardian of the person; attorney for personal care;
representative appointed by the Consent and Capacity Board; spouse or partner; child or
parent; brother or sister; any other relative, Public Guardian and Trustee as last resort.
Procedure
1.
Assess patient’s need for restraint.
•
Conduct a comprehensive assessment of the patient including:
a.
b.
cognitive status (level of confusion)
potential for falls
This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by
any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without
permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number
Section
Issued By
Approved By
3.30.007
Safety & Special Needs
Fall Safety & Restraints Committee
Nursing & Allied Health Executive
Committee; Medical Advisory Committee;
UHN Operations Committee
Original Date
Revision Date(s)
Review Date
Page
06/93
03/96; 08/01; 07/02; 01/04; 05/05
4 of 12
c.
d.
e.
2.
potential for wandering
a review of the patient’s history in relation to prior application of restraints
condition(s) that led to the patient’s current behaviour (e.g., emotional/
behavioral, pharmaceutical, cognitive, and physical status of patient)
Explore alternatives to restraints with the patient/family/SDM.
•
Speak with the patient's family/SDM regarding:
a.
b.
•
•
measures used at home to ensure patient's safety and well being
the family's availability to assist with patient's care in hospital (e.g., sit with
the patient for periods of the day)
Use reality orientation methods such as:
a.
Communicating with the patient by talking or touching.
b.
Orienting the patient to person, place and time.
c.
Leaving a night light on at night.
d.
Raising the head of the bed to increase visual fields.
e.
Placing a calendar in the room.
f.
Turning a radio on.
Implement a location change by:
a.
Moving the patient closer to the nursing station.
b.
Moving the patient to a more or less stimulating environment, depending
on the assessment of the patient's needs.
Use products/devices which protect the patient without restricting movement
(e.g., skin sleeve to protect IV/wound sites and skin from tear and abrasion).
•
Walk, exercise or otherwise increase mobility of a restless and/or wandering
patient.
•
Consult the Physiotherapist to help improve the patient’s balance, strength,
transfers and ambulation to increase safety and well being.
•
Consult the Occupational Therapist for a seating assessment.
This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by
any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without
permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number
Section
Issued By
Approved By
3.30.007
Safety & Special Needs
Fall Safety & Restraints Committee
Nursing & Allied Health Executive
Committee; Medical Advisory Committee;
UHN Operations Committee
Original Date
Revision Date(s)
Review Date
Page
06/93
03/96; 08/01; 07/02; 01/04; 05/05
5 of 12
Note: Safe, comfortable seating is an important factor for reducing the need for
restraints for patients with impaired mobility due to physical or cognitive
behaviour.
•
Provide appropriate lighting which is non-glare but adequate for orientation and
vision to prevent falls.
•
If there is a risk of hip fracture, consider use of hip protectors.
•
Place the commode at the bedside with the brakes on.
•
Keep the bed in the low position.
•
Rearrange the furniture in the room to clear obstacles from the patient’s path.
•
Post signs to help the patient find his or her room, toilet, etc.
•
Keep the call bell within easy reach.
•
Remove hazardous objects (e.g., sharps container).
•
Pay close attention to bladder/bowel function: toileting the patient every 3 hours
or according to the patient's individual requirements.
•
Review the patient’s medications:
•
3.
a.
Seek advice from Pharmacist.
b.
Check the side effects.
c.
Check the paradoxical effects.
d.
Check for appropriateness of the medication ordered.
Arrange for constant observation by appropriate member of health care team
(requires authorization by Nurse Manager/delegate)
Discuss with the family/SDM the use of restraints in the event that alternatives are
ineffective and/or impractical.
•
Provide the patient/family/SDM with the Patient Safety–Use of Restraints at
University Health Network (form 3283) information handout.
This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by
any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without
permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number
Section
Issued By
Approved By
3.30.007
Safety & Special Needs
Fall Safety & Restraints Committee
Nursing & Allied Health Executive
Committee; Medical Advisory Committee;
UHN Operations Committee
Original Date
Revision Date(s)
Review Date
Page
06/93
03/96; 08/01; 07/02; 01/04; 05/05
6 of 12
•
Obtain informed consent from the patient (if the patient is competent) or from
the SDM (if the patient is incompetent) using the Consent to Treatment (form
2019A). (Refer to Consent to Treatment policy 3.20.001.)
Notes: The signed Consent to Treatment is applicable for the duration of the
patient’s stay in hospital.
If restraints are required in an emergency situation (e.g., Code White),
informed consent must be obtained and documented within 4 hours of the
initiation of restraints.
4.
Document in the Clinical Notes the details of the discussion with the patient/SDM
about the plan for using restraints.
5.
Obtain a Doctor’s Order/Medical Directive for initiation of restraints. The order must
include:
•
•
type of restraint applied
condition for which the restraint is being used
Restraint
Indications for Use
Posey
Freedom Splint
Posey
Peek-a-Boo Mitt
Posey
Quick-Release Limb Holder
Posey
Twice as Tough cuff
Patient is combative or agitated and likely to pull IV line/
catheter or tubes.
Posey
Roll Belt
Patient has been assessed as being at risk for falls; or
patient requires restraint to assist with medical
treatment
Posey
Soft Belt (seat belt)
Patient is at risk for forward sliding, falling out of bed, or
requires assistance with ambulation
IV Access Jacket
Patient is agitated, combative, pulling at lines and/or
tubes, getting out of bed against medical advice, or
requires assistance with medical treatment. Allows
access to IV lines and monitoring lines
Posey
Patient is pulling at IV line/catheter or other tubes or is
likely to cause self injury
Geri-chair with lap tray
Patient at risk for sliding out of chair
Hard leather limb restraints
Patient is violent – for use only on Psychiatric Units
Lock and key restraints (e.g.,
Pinels®)
For patients detained under the Mental Health Act – for
use only on Psychiatric Units
Patient monitoring device
For patients assessed at risk for wandering – see
Wandering Patient policy 3.30.017
•
For application of these devices, refer to Use of Restraint: Application
Instructions and Videos in Patient Restraints on the UHN Nursing website.
This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by
any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without
permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number
Section
Issued By
Approved By
3.30.007
Safety & Special Needs
Fall Safety & Restraints Committee
Nursing & Allied Health Executive
Committee; Medical Advisory Committee;
UHN Operations Committee
Original Date
Revision Date(s)
Review Date
Page
06/93
03/96; 08/01; 07/02; 01/04; 05/05
7 of 12
6.
If a patient requests to have all bed rails raised, ensure the bed is in the lowest
position, and the call bell is within easy reach.
7.
Observe the patient and environment according to the appropriate level of
observation.
8.
Release restraints q2h to provide patient care.
9.
Reassess need for restraints at least q shift.
10. Obtain a new Doctor’s Order/Medical Directive for initiation of restraints q24 hours.
Patient/SDM Opposes Restraint
1.
Approach the SDM for consent to restrain the patient.
2.
If the SDM opposes restraint and cannot provide an effective alternative:
3.
•
Inform the physician.
•
Notify Patient Relations.
If the patient poses an imminent risk of harm to self and/or others:
•
Restrain the patient.
•
Notify the physician for an assessment and/or detention of the patient under
the Mental Health Act, and request a psychiatric consult.
•
Obtain the doctor’s order or write the medical directive for restraint.
•
Document, in the Clinical Notes, all events, decisions, subsequent actions, and
patient’s response.
Note: Patients detained under the Mental Health Act can be restrained in an emergency
before a doctor’s order is obtained. (Refer to the Mental Health Act,1990 at
http://www.e-laws.gov.on.ca/DBLaws/Statutes/English/90m07_e.htm.)
SDM Requests Restraint Against Medical Advice
If an SDM is insistent that a patient be restrained despite the Health Care Team advising
against restraint:
1.
Inform the physician.
2.
Notify Patient Relations.
This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by
any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without
permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number
Section
Issued By
Approved By
3.30.007
Safety & Special Needs
Fall Safety & Restraints Committee
Nursing & Allied Health Executive
Committee; Medical Advisory Committee;
UHN Operations Committee
Original Date
Revision Date(s)
Review Date
Page
06/93
03/96; 08/01; 07/02; 01/04; 05/05
8 of 12
3.
Document, in the Clinical Notes, all events, decisions, subsequent action taken,
and patient’s response.
Application of Restraints
1.
Attach restraint straps (Posey jacket, wrist, ankle, mitts) only to the bed frame
that supports the mattress not to the bed frame that supports the bed wheels.
Incorrect attachment (e.g., bed rails) of the restraint straps can result in adverse
patient outcomes.
2.
If not using a universally-sized restraint, choose the appropriate restraint size for
the patient.
3.
If both limbs require restraint place the patient in a side lying position and secure
both limbs to the same side.
4.
Always examine restraints before application to ensure that they are in good
working order. Replace when required.
5.
For complete instructions on the application of UHN-approved mechanical
restraints, see Use of Restraint Application Instructions and Videos in Patient
Restraints on the UHN Nursing website.
Monitoring & Care of Patients in Restraints
1.
Nursing staff observes the patient’s physical behavior and psychological status
according to the level of observation indicated.
2.
Give specific consideration to:
•
•
•
•
•
•
•
•
•
•
•
patient response to restraint, and whether the restraint is having the desired
effect
the positioning of the restraint
need for ongoing use of restraints each shift
level of alertness and orientation
affect and emotional well being
need for socialization
pain or discomfort related to the restraint
opportunity for discussion of thoughts, feelings and worries regarding restraint
need for care provision (toileting, hygiene, nutrition)
opportunity for physical activity, re-positioning, and skin care
circulation to extremities to which a restraint is applied
This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by
any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without
permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number
Section
Issued By
Approved By
3.30.007
Safety & Special Needs
Fall Safety & Restraints Committee
Nursing & Allied Health Executive
Committee; Medical Advisory Committee;
UHN Operations Committee
Original Date
Revision Date(s)
Review Date
Page
06/93
03/96; 08/01; 07/02; 01/04; 05/05
9 of 12
Documentation
1.
Ensure a signed Consent to Treatment (form 2019A) is filed in the patient’s health
record.
2.
Ensure that a Doctor’s Order/Medical Directive (written within the past 24 hours) is
on the chart.
3.
In the Clinical Notes, document the initiation of restraints including behaviour
observed, alternatives tried, type of restraint applied, and patient/family/SDM
response.
4.
While a patient is in restraints, document routine observations using the following:
•
•
•
5.
Patient Care Record (form 2370) (See Patient Care Record policy 3.110.014.)
Vital Signs Record (form 2191) (See Vital Signs Record policy 3.110.018.)
24 Hour Fluid Balance Record (form 3101) (See Fluid Balance Record
policy 3.110.003.)
Document the following in the Clinical Notes:
•
•
•
•
change in patient status
change in restraint type
discontinuation of restraints
patient’s response
Ordering & Maintaining Approved Restraints
1.
Units and departments, where applicable, maintain an adequate supply of
approved restraints.
2.
If more restraints are required, contact Shared Healthcare Supply Services (SHSS)
at http://intranet.uhn.ca/hospitals_associates/shss/ to top up the unit supply.
3.
Follow the instructions on the manufacturer package inserts for use, cleaning,
disposal and/or maintenance of the restraints.
4.
For cleaning non-disposable restraints, place soiled restraints into the laundry bag
clearly marked with the unit name and location, and send it to the in-house laundry
at each site.
This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by
any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without
permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number
Section
Issued By
Approved By
3.30.007
Safety & Special Needs
Fall Safety & Restraints Committee
Nursing & Allied Health Executive
Committee; Medical Advisory Committee;
UHN Operations Committee
Original Date
Revision Date(s)
Review Date
Page
06/93
03/96; 08/01; 07/02; 01/04; 05/05
10 of 12
References
1.
Registered Nurses Association of Ontario (2002). Prevention of falls and fall
injuries in the older adult. Toronto, Canada: Registered Nurses Association of
Ontario.
2.
Bill 85 2001. Patient Restraints Minimization Act, 2001. Journals and Procedural
Research Branch, Office of the Legislative Assembly of Ontario. Toronto, ON, Dec
2001. http://www.e-laws.gov.on.ca/DBLaws/Statutes/English/01p16_e.htm
3.
Walker-Renshaw, B. Ontario’s New Patient Restraints Minimization Act, 2001:
Codifying a policy of least restraint. Borden Ladner Gervais LLP, Toronto, ON.
2001.
4.
Marcy-Edwards, D. Bed Rails: Is there an up side? Canadian Nurse, Vol 101,
No 1, Jan 2005: 30-34.
This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by
any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without
permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number
Section
Issued By
Approved By
3.30.007
Safety & Special Needs
Fall Safety & Restraints Committee
Nursing & Allied Health Executive
Committee; Medical Advisory Committee;
UHN Operations Committee
Original Date
Revision Date(s)
Review Date
Page
06/93
03/96; 08/01; 07/02; 01/04; 05/05
11 of 12
R e s t ra in t M in im iz a t io n D e c is io n -M a k in g P r o c e s s
A s s e s s p a tie n t
P o te n tia l fo r in ju r y to s e lf a n d /o r o th e rs id e n tif ie d
Is it a n
e m e rg e n c y
s itu a tio n ?
Yes
V io le n t P a tie n t
P o s in g d a n g e r to
s e lf/o th e rs
N o n - v io le n t P a t ie n t
P o s in g im m e d ia te
r is k to s e lf
C a ll C o d e W h ite
C h o o s e m e th o d o f le a s t
re s tr a in t
No
P a tie n t d e ta in e d
u n d e r M e n ta l
H e a lth A c t?
Yes
C o n s u lt w ith
P s y c h ia tr y
No
C o lla b o r a t e w ith h e a lt h c a r e te a m , p a t ie n t /
f a m ily /S D M to id e n tify :
C o n tr ib u tin g fa c to r s to p a tie n t's
b e h a v io u r
P o te n tia l m e th o d s to re d u c e r is k o f
in ju r y b y p a tie n t to s e lf a n d /o r o th e r s
A p p ly r e s tra in t
O b ta in c o n s e n t a n d p h y s ic ia n
o rd e r fo r s p e c ific r e s tr a in ts
( w ith in 4 h o u rs o f a p p lic a tio n )
A lt e r n a tiv e s to
re s tra in ts im p le m e n te d
a n d e ffe c tiv e ?
D ocum ent
C o n tin u e to m o n ito r p a tie n t
Yes
Docum ent
M o n ito r
p a tie n t
No
Is th e a c u te
s itu a tio n
re s o lv e d ?
No
C o n s u lt w ith p a tie n t/fa m ily /S D M to
p la n fo r a p p lic a tio n o f r e s tra in ts
C h o o s e m e th o d o f le a s t r e s tra in t
Yes
O b ta in c o n s e n t a n d p h y s ic ia n o r d e r
R e m o v e re s tr a in t
D ocum ent
M o n ito r p a tie n t
Im p le m e n t p la n
P r o v id e o n g o in g s u p p o rt/e d u c a tio n to
p a tie n t/f a m ily /S D M
D o c u m e n t in p a tie n t's c h a rt
C o n tin u e to m o n ito r p a tie n t
R e - e v a lu a te r e s tr a in t u s e a s p e r
p o lic y
R ev Jan 05
This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by
any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without
permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number
Section
Issued By
Approved By
3.30.007
Safety & Special Needs
Fall Safety & Restraints Committee
Nursing & Allied Health Executive
Committee; Medical Advisory Committee;
UHN Operations Committee
Original Date
Revision Date(s)
Review Date
Page
06/93
03/96; 08/01; 07/02; 01/04; 05/05
12 of 12