Exploring the use of bedrails when used to support adults: A scoping review.

Bedrails, Adults, Hospital, Community, Own Home, Nursing Home, Clinical Drivers, Harm, Falls Prevention, Risk, Ethics, UK, US. ALL Metrics - Views Downloads How to cite this article Farrell V, Hall A and Goodwin V. Exploring the use of bedrails when used to support adults: A scoping review. [version 3; peer review: 1 approved, 1 approved with reservations]. NIHR Open Res 2026, 5:22 (https://doi.org/10.3310/nihropenres.13829.3) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente Select a format first ▬ ✚ Systematic Review Revised Exploring the use of bedrails when used to support adults: A scoping review. [version 3; peer review: 1 approved, 1 approved with reservations] Vicky Farrell https://orcid.org/0009-0007-8461-6759 1,2, Abigail Hall https://orcid.org/0000-0002-3453-5631 2, Victoria Goodwin2Vicky Farrell https://orcid.org/0009-0007-8461-6759 1,2, Abigail Hall https://orcid.org/0000-0002-3453-5631 2, Victoria Goodwin2 PUBLISHED 16 Apr 2026 Author details Author details 1 Cornwall Partnership NHS Foundation Trust, Bodmin, England, UK 2 Faculty of Health and Life Sciences, University of Exeter, Exeter, UK 2 Faculty of Health and Life Sciences, University of Exeter, Exeter, UK Vicky Farrell Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Abigail Hall Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Resources, Software, Supervision, Validation, Visualization, Writing – Review & Editing Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Resources, Software, Supervision, Validation, Visualization, Writing – Review & Editing Victoria Goodwin Roles: Conceptualization, Software, Supervision, Writing – Review & Editing Roles: Conceptualization, Software, Supervision, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS In the UK, concerns regarding the safe use of bedrails, especially in nursing homes and a person’s own home, prompted a National Patient Safety Alert in August 2023. A scoping review was conducted to identify and map the literature relating to bedrail use in hospital and community settings and identify future areas of research. The scoping review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Scoping Review guidelines. The search was conducted using MEDLINE, EMBASE, EMCARE, COCHRANE, BASE, CINAHL, and Google Scholar. Two reviewers independently contributed to screening. Data extraction included clinical drivers of bedrail prescription, prevalence of use, and causes of harm. Findings were reported narratively. The scoping review identified a heterogeneous and predominantly descriptive evidence base relating to adult bedrail use, focused largely on inpatient and long-term care settings. Evidence was most developed at the micro-level, where audit-based studies demonstrated strong associations between bedrail use and patient characteristics, particularly immobility. A consistent association was also identified in UK inpatient settings between bedrail use and patients described as very confused. In contrast, clinical rationales for bedrail use, including falls prevention and prevention of bed exit were frequently reported but poorly defined and inconsistently operationalised. Evidence relating to meso- and macro-level drivers of bedrail use, including organisational culture, policy, and national guidance, was limited and largely narrative. Studies reporting the impact of harm reported inconsistent findings, with serious adverse events primarily identified through incident and national surveillance data. Comparative evidence evaluating alternatives to bedrails and user experience was sparse. Bedrail use continues in the context of limited empirical evidence, significant uncertainty, and ethical and medico-legal complexity. Further research using methodologies capable of addressing contextual and ethical factors across care delivery settings is needed to better inform practice and policy. Bedrails are a medical device that attach to the side of electric beds or are built into their design and are used with the intention of reducing the risk of someone accidentally falling out of bed. However, in 2023 the UK government issued a national safety alert after reports of serious injury and death linked to bedrails. These incidents occurred when people became trapped in the rails or suffocated in gaps between the mattress and rails. This study reviewed and mapped existing research to understand why bedrails are used, what benefit they are intended provide, what harms have been reported, and how people involved in decisions about bedrails experience their use. Searches of scientific databases policy sources identified very little strong scientific evidence to guide clinical practice. Thirty-three papers were included, most of which described bedrail use in a narrative way rather than evaluating outcomes. The review found that decisions about bedrails are strongly influenced by how mobile or confused a person is perceived to be, as well as by local ward or care setting culture. Clinicians therefore make complex decisions under uncertainty, balancing patient safety, ethical concerns, and legal risk. Further research is needed to better support these decisions. Bedrails, Adults, Hospital, Community, Own Home, Nursing Home, Clinical Drivers, Harm, Falls Prevention, Risk, Ethics, UK, US. Corresponding Author(s) Vicky Farrell ([email protected]) Grant information: This project is funded by the National Institute for Health and Care Research (NIHR) under its [‘Research for Patient Benefit (RfPB) Programme’ (Grant Reference Number PB-PG-NIHR305094)]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2026 Farrell V et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Farrell V, Hall A and Goodwin V. Exploring the use of bedrails when used to support adults: A scoping review. [version 3; peer review: 1 approved, 1 approved with reservations]. NIHR Open Res 2026, 5:22 (https://doi.org/10.3310/nihropenres.13829.3) First published: 10 Mar 2025, 5:22 (https://doi.org/10.3310/nihropenres.13829.1) Latest published: 16 Apr 2026, 5:22 (https://doi.org/10.3310/nihropenres.13829.3) The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. An additional sentence has been added in the results section to define the terms micro, meso, and macro. Additional details have been added to the PPIE statement. While the DOI numbers for data files 2 and 3 were correct, the links were broken. I have generated new links from OSF and replaced. An additional sentence has been added in the results section to define the terms micro, meso, and macro. Additional details have been added to the PPIE statement. While the DOI numbers for data files 2 and 3 were correct, the links were broken. I have generated new links from OSF and replaced. See the authors' detailed response to the review by Safiyyah M. Okoye Bedrails form a barrier along the edge of a bed, and are available in a range of designs, lengths, and materials. In the United Kingdom, when bedrails are prescribed with a clear medical purpose they are classified as a medical device.1 Bedrails are commonly used to support adults by reducing the likelihood of falls from bed due to a slip, slide, or roll.1,2 Bedrails may be considered in situations such as a person transitioning from a double to single bed,3 when undertaking functional tasks while sitting up in bed (e.g. eating and drinking, or communicating), or when bedrails are recommended by the manufacturers of moving and handling equipment. Examples of these include patient repositioning systems that may incorporate slide sheets, lateral turning systems that are positioned beneath or above the mattress, or repositioning systems designed for use by a single carer in combination with an overhead hoist. In the UK, bedrails must never be used as a physical restraint in an attempt to limit or prevent a person’s ability to exit their bed,1,4,5 or as a turning aid where a person pulls on the rails to reposition themselves.2 Despite their intended purpose, bedrails are associated with recognised risks. In August 2023, the UK Medicines and Healthcare products Regulatory Agency (MHRA) issued a National Patient Safety Alert (NPSA) drawing attention to risk of death from entrapment or entanglement in bedrails, particularly in nursing homes and in a person’s own home.4 Between 1st January 2018 to 31st December 2022, 18 deaths and 54 reports of serious injuries related to bedrails and associated equipment were reported to the MHRA,1 highlighting the potential for serious harm associated with bedrail use. These risks translate into complex decision-making in practice and are further compounded by reports of civil and clinical negligence claims relating to inpatient falls, both when bedrails are used and when they are withheld.6–8 As a result, clinicians are required to reconcile patient safety, autonomy, and risk within specific care contexts, alongside the availability of bedrail risk mitigation strategies such as in-person supervision or observation. These decisions are made while navigating organisational and medico-legal pressures that influence how prescribing decisions and made and justified. The capacity for organisations to learn from adverse events is further constrained by inconsistent documentation and variability in incident reporting, root cause analyses, and patient records.8 Together, these factors may limit reflective learning and contribute to the persistence of established practices, rather than supporting iterative improvement in the quality and safety of patient care. Nevertheless, the evidence underpinning bedrail use remains limited. A 2007 systematic literature review exploring the use of bedrails in hospitals reported that the majority of included studies were small, descriptive, or opinion based, with no randomised controlled trials identified, resulting in an absence of robust evidence regarding effectiveness or safety.2 In 2023, the NPSA required all UK organisations involved in bedrail use to review and update all bedrail policies and procedures.4 Internationally, ensuring access to safe and effective medical devices is a strategic priority of the World Health Organisation.9 In this context, an up-to-date scoping review was undertaken to identify and map existing evidence on the use of bedrails to support adults and identify gaps in the literature that may inform future research and clinical practice. This study was informed by concerns raised by family members and caregivers with a lived experience of bedrail use. In August 2023, the NPSA required that all individuals using bedrails in the UK be reviewed and associated risk assessments updated within six months.4 The review of existing bedrail prescriptions prompted significant concern among some stakeholders, including bedrail users and their families, regarding potential impact on care arrangements and personal autonomy. Throughout this project, the author undertook informal consultations with individuals who use bedrails, their representatives, and care partners to explore whether research in this area was warranted and to identify priorities for investigation. Contributors highlighted the importance of this topic, noting that decisions regarding bedrail use may substantially affect 24-hour care planning financial cost of care, equipment requirements, and perceived restrictions on personal liberty. Contributors also reported that decisions relating to bedrail use may be experienced as distressing especially when decisions around use were escalated to increasing levels of authority such as safeguarding teams or the Court of Protection. A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guideline.10 The review protocol was developed a priori and is available via the Open Science Framework (OSF) repository.11 Informed by the findings of the previous literature review,2 broad search terms were used to capture the diversity of literature on bedrail use. The S.P.I.D.E.R framework12 was selected to support the development of an inclusive search strategy. Inclusion Sample: Adults Phenomenon of Interest: Bedrails Design: Studies where the primary focus was the use of bedrails. No restrictions were placed on publication date or language. Evaluation: Any Research Type: Any Exclusion The following electronic databases were searched: MEDLINE and EMBASE (via OVID), EMCARE, Cochrane Library, CINAHL (via EBSCOhost), and the Bielefeld Academic Search Engine. Backward citation tracking of key documents was undertaken. Gray literature13 was identified using Google Scholar with the intention of capturing policy documents, professional guidance, audit reports, theses, and organisational publications not indexed in bibliographic databases. Key authors were contacted to request additional evidence where relevant material was not publicly available. The full search strategy, conducted on 6th March 2024, is provided in the appendices hosted in the OSF repository.14 Searches were updated on 7th January 2026. “Bed rail*” OR “bedrail*” OR “side rail*” OR “siderail*” OR “cot side*” OR “cotside*” AND “adult*” OR “older person*” OR “elderly” AND “community” OR “dwelling” OR “home” OR “care home” OR “residential home” OR “nursing home” OR “supported living” OR “hospice” OR “hospital” OR “unit*,” Database search results were exported to EndNote v.21, duplicates removed and records subsequently uploaded to Rayyan15 for screening. Title and abstract screening was conducted independently by two blinded reviewers using predefined eligibility criteria. Owing to time constraints, full-text screening was primarily undertaken by one reviewer, with a second reviewer independently screening 10% of full text articles to assess consistency and reliability. As agreement between reviewers was consistent, this proportion was maintained for the remainder of the screening process. Any discrepancies were resolved through discussion, and involvement of a third reviewer was not required. Data were extracted from included studies by one reviewer using an a priori data extraction table and checked for accuracy by a second reviewer. In keeping with scoping review methodology, formal quality appraisal of included studies was not undertaken. Given the heterogeneity of study designs and the exploratory, pragmatic nature of the evidence base, extracted data were synthesised narratively. Data extraction was iterative and involved ongoing familiarisation and refinement of analytic categories. Table 1 Data extraction framework is located in the OSF repository.17 Searches were updated in January 2026 and no additional citations meeting the inclusion criteria were identified. Thirty-three papers were included in the review. Publication dates ranged from 1983 to 2024 and primarily originated from inpatient hospital settings in the UK and United States. Limited information was identified that explored the use of bedrails in a person’s own home. Many of the published papers were reports or opinion pieces made by those working in the care of older adults. The results section is structured around five themes identified within the literature; clinical drivers of bedrail use, prevalence of use, the impact and reported harm associated with bedrails, experiences of people involved in decisions about bedrails use, and the balancing of competing ethical imperatives when considering whether to prescribe or withhold bedrails. These themes are presented in the sections that follow. Prescribers of bedrails appeared to draw on factors operating at both micro- and meso-levels when explaining clinical decisions regarding bedrail use, where micro refers to individual patients and prescribers, meso to organisational policies and procedures, and macro to national policy, legislation, or regulatory conditions. Several studies reported clinical rationales for bedrail use, most commonly falls prevention, prevention of bed exit attempts, use to support turning in bed, or at the request of the patient or family. These rationales were typically captured through staff surveys or audit tools. However, in many cases the underlying survey instruments were not reported, limiting insight into how these concepts were defined, understood, or operationalised. For example, studies citing prevention of bed exit attempts as a clinical rationale, did not report what underlying risks or contexts necessitated the use of bedrails. Across the included literature, micro-level drivers were the most frequently cited and empirically examined. Several audit-based studies using multivariable analyses reported statistically significant associations between patient characteristics and the presence of bedrails. For example, in a large cross sectional, observational study conducted across seven UK NHS trusts (n = 1092), patients described as immobile were substantially more likely to have bedrails in place when compared with those described as independently mobile (adjusted odds ratio (AOR) 62.5, 95% confidence interval (CI) 27.4 to 142.8), indicating a strong association between immobility and bedrail use, despite the uncertainty in the magnitude of the effect.21 In addition to immobility, cognitive status was also associated with bedrail use in UK based audit studies. Healey et al. reported that patients described as very confused were significantly more likely to have full bedrails raised than those described as not confused (AOR 7.8, 95% CI 3.7 to 16.5).21 Similarly, Hignett et al. identified an increased likelihood of bedrail use among patients described as very confused compared with those described as not confused (AOR 2.62, 95% CI 1.68 to 4.09).22 These findings indicate a consistent association between reported confusion and bedrail use across UK inpatient settings. Several older studies identified meso-level drivers of bedrail use, including organisational policy, professional culture, and organisational risk management in response to concerns regarding litigation. In particular, some U.S. based literature described bedrail use as culturally accepted or routine practice for new admissions, reflecting established organisational norms rather than individualised clinical assessment.35,38 Few studies explicitly examined macro-level drivers influencing bedrail use, such as national policy, regulatory frameworks or broader political and legal contexts. Where macro-levels were discussed, this was largely confirmed to opinion pieces concerning the limited national or professional guidance, or evidence based frameworks. Several studies and reports referenced potential alternatives to bedrails or factors that should be considered prior to prescribing, such as environmental modification, enhanced supervision, floor beds, or individual risk assessment that may include medication review and continence care plans. However, these alternatives were discussed descriptively rather than evaluated empirically. No studies were identified that compared bedrails with alternative interventions in terms of effectiveness, safety, or patient outcomes. As a result, suggestions regarding alternatives were largely speculative and not supported by comparative or robust evidence. Prevalence of bedrail use was most frequently captured using snapshot audit-based studies, defined as observational reviews of occupied inpatient beds, conducted at a single point in time, in hospital or long-term care homes. Many audits explicitly excluded specialist clinical areas such as high dependency units, critical care, cardiac units, emergency care environments, and maternity units, thereby limiting applicability of findings to these settings. Data were reported as a binary outcome of either bedrails in use (raised or partially raised) or not in use and findings presented as a percentage of total occupied beds using bedrails. Across UK and Irish acute inpatient wards, full or partial raised bedrails were observed to be raised in approximately 16% to 52% of total occupied beds.18,20–23 Variation in bedrail use was reported both within and between organisations. For example, Noore et al. identified a lower prevalence of raised bedrails in a geriatric ward when compared with other wards within the same district general hospital (7% occupied beds versus 19% in other wards).18 Healey et al. found significant variation in bedrail use across seven NHS Trusts, with no clear relationship between the presence or content of bedrail policy and observed bedrail use. No interaction effects were detected between organisational bedrail use and patient age, mobility, confusion, bed type, or mattress type. After adjustment for these variables, the likelihood of full bedrails being raised in one NHS organisation was ten times more likely when compared to another.21 Several studies examined the impact of interventions intended to reduce bedrail use on the overall number of falls that occurred within the patient bedspace. These studies were predominately observational and included before-and-after designs implemented within hospital inpatient or long-term care settings and falls outcomes were captured through internal incident reporting systems. Across these studies, changes in bedrail use were not consistently associated with a significant change in falls rates. Some studies reported no change in the number of falls34,35 whilst others had mixed findings.36 Authors frequently acknowledged methodological limitations, including reliance on incident report data, limited control for confounding variables, and variability in how falls were defined and recorded. Across the before-and-after studies, exposure to bedrails was inconsistently reported or not reported at an individual patient level. For example, it was not possible to identify if a person who experienced a fall in the before or after period of the studies were using bedrails at the time of the fall.35 Reports of harm associated with bedrail use were identified primarily through reviews of organisational incident reports38 and reports submitted to national regulatory or governing bodies.1,39,40,43–46 These sources described adverse events including limb entrapment, asphyxiation, and death occurring across a range of care settings. Several authors noted limitations in the available data, including incomplete reporting, lack of independent verification, and absence of denominator data, limiting estimation of incidence or risk. In many cases, contributory factors such as equipment incompatibility, incorrect assembly, use of mattress overlays (that increase the height of the mattress in relation to the height of the bedrails), or inadequate patient monitoring were described. Evidence relating to harm associated with bedrail use was also identified in a review of NHS clinical negligence claims relating to inpatient falls. Between 1995 to 2006, bedrails were listed as the primary cause of harm in 11.9% of claims, while the absence of bedrails was cited in 10.6% of claims.7 All claims were settled out of court and no legal rulings establishing liability or causation were available. The mean payment per claim was £12945, with authors noting that difficulties in establishing causation were compounded by patient frailty, multiple comorbidities, and limitations in documentation.7 Evidence relating to the experience of bedrail use from the perspective of patients and their families was limited and predominantly descriptive in nature. Where reported, some patients expressed a preference for bedrails, describing feelings of safety. In several studies, family request was cited as clinical rationale for bedrail use, although the context and basis of those preferences were not explored. Family members and care partners were also reported to influence bedrail use, particularly in long-term care and inpatient settings, where bedrails were perceived as contributing to patient safety. Overall, reporting was indirect, relying on staff perceptions of clinical rationale rather than first-hand accounts. Experiences of bedrail reduction were also reported indirectly through descriptions of implementation challenges in before-and-after studies. Authors described reluctance and scepticism among staff, patients, and families when attempts were made to reduce bedrail use, with particular emphasis on the time and effort required to engage stakeholders on the topic, conduct individual assessments, and discuss alternatives to bedrails.35 In one study conducted across three US nursing homes, routine use of raised bedrails for all new admissions persisted despite multidisciplinary involvement, updated assessments, and targeted strategies such as ‘rail rounds,’ reflecting entrenched practices and resistance to change.36 Ethical considerations relating to bedrail use were discussed in several studies, most often in narrative or opinion-based literature rather than empirical investigations. Authors commonly describe ethical tensions between the perceived need to maintain patient safety, particularly in relation to falls prevention, and the preservation of patient autonomy, dignity, and freedom of movement in pursuit of meaningful occupations of time. Bedrails were inconsistently described as both a supportive device and a restrictive intervention, with few studies providing explicit criteria for distinguishing between these interpretations. Concerns regarding restraint and restriction in liberty were raised in a number of sources, particularly within UK based literature, where bedrails were explicitly described as inappropriate when used to restrict movement rather than to mitigate specific falls risk.2 Ethical concepts were often described implicitly or presented as opinions expressing concern that ethical considerations should form part of a bedrail assessment. Overall, whilst the literature highlighted ethical complexity and ambiguity surrounding bedrail use, limited empirical insight into how competing ethical imperatives were balanced in clinical practice was identified. This scoping review aimed to identify and map the literature relating to the use of bedrails to support adults. A heterogeneous and predominantly descriptive evidence base relating to the use of bedrails across inpatient and long-term care settings was identified, originating primarily from the UK and the US. Across studies, clinical rationales for bedrail use, such as falls prevention or prevention of bed exit, were frequently reported. The majority of evidence was developed at the micro-level, where audit-based studies demonstrated strong associations between specific patient characteristics, particularly immobility, and the presence of bedrails. A consistent association was also identified in UK inpatient settings between bedrail use and patients described as very confused. Prevalence of bedrail use varied widely between and within organisations, with variation observed irrespective of the presence of local bedrail policy. This scoping review has several methodological limitations. Due to time constraints, full-text screening was primarily conducted by a single reviewer, with ten percent of studies independently screened by a second. Data extraction was undertaken by one reviewer with verification by a second rather than duplicate extraction on a subset of studies. These approaches are consistent with a pragmatic scoping review methodology but may have increased the potential for selection or extraction bias. An additional limitation is the inconsistent framing of bedrails within international literature, where bedrails are variably discussed as a falls prevention device or as a restrictive intervention. This lack of conceptual clarity may have affected synthesis, as authors were not always addressing the same underlying purpose or mechanism of use, despite employing the same terminology. A key strength of this review is the integration of patient and public involvement, which informed the focus of the inquiry and ensured that the review addressed relevant issues to those directly affected by bedrail use and prescribing decisions. The findings of this scoping review are consistent with those reported in 2007 by Healey et al. which similarly identified a limited body of empirical research examining bedrail use, predominantly within inpatient and long-term care settings.2 Challenges in advancing research in this area have been recognised for several decades. As early as 1983, Rubenstein et al. highlighted the need for a randomised controlled trial to evaluate bedrail use but concluded that such a study would be difficult, if not impracticable to design and implement.38 This ongoing methodological challenge may partly contextualise the continued reliance on observational and descriptive approaches within the literature. The findings of this review suggest that bedrails may function, in part, as a response to perceived falls risk in situations where patients are viewed as vulnerable or unpredictable. Decisions regarding bedrail use are frequently made in the context of limited empirical evidence and in the absence of clearly articulated or defined mechanisms of action. While patient characteristics such as immobility were strongly associated with bedrail use, these associations alone do not explain the clinical reasoning underpinning individual prescribing decisions. Across the literature, rationales for bedrail use were often broad, variably defined, and inconsistently operationalised, with limited links to measurable outcomes. This disconnect between empirically observed patterns of use and the rationales offered to justify them underscores the complexity of decision-making in this area, where clinicians are required to balance the potential for harm associated with bedrails against perceived benefits in the face of uncertainty. When making decisions about bedrail use and in the absence of robust evidence or explicit decision-making frameworks, clinicians appear to rely on heuristics, risk perceptions, and contextual factors rather than organisational policy. Reports of difficulty implementing bedrail reduction strategies suggest that entrenched local norms of practice, staff and family expectations, and perceptions of risk exert a stronger influence on practice than written guidance. In this context, bedrail use appears to be sustained by local cultures of care and defensive practice, contributing to persistent variation despite awareness of potential harm. These patterns highlight the challenges inherent in individualised decision-making where risk is difficult to assess, articulate, or quantify, and where the intended purpose of bedrail use, its mechanism of action, and associated outcomes remain uncertain. Ethical and medico-legal uncertainty was also evident across the literature. Evidence from NHS negligence claims indicates that bedrails are cited both in cases when they were used and when they were not, suggesting that they are perceived simultaneously as both protective and harmful devices. This ambiguity is reflected in a 2025 Delphi consensus study examining falls prevention strategies in hospital settings, which concluded that bedrails could not be recommended as a reference standard for falls prevention due to concerns regarding patient safety and routine use.48 This conclusion was informed by the 2022 World Guidelines for Falls Prevention and Management for Older Adults, which explicitly identify bedrails as a form of restraint.49 The framing of bedrails as both a falls prevention device and a restrictive intervention illustrates the ethical and clinical complexity faced by clinicians when considering their use, with implications not only for clinical accountability but also for patients and families who may experience uncertainty and distress regardless of whether bedrails are used or withheld. A pragmatic, realist evaluation of bedrail use across acute inpatient, long-term care, and home settings may offer a more appropriate approach to understanding how context, mechanisms, and outcomes interact within different care environments. In addition, qualitative research examining clinical decision-making regarding bedrail prescription could provide valuable insight into how organisational policy, cultural norms of practice, contextual variables and ethical, and medico-legal concerns are balanced in situations characterised by uncertainty. Such work could help inform future practice and guide the development of more context-sensitive research. This scoping review demonstrates that evidence relating to the use of bedrails remains limited, heterogenous and predominantly descriptive. There is little empirical evidence evaluating the use of bedrails as a falls prevention intervention, and substantial gaps persist in relation to user experience and bedrail use within a person’s own home. Decisions regarding bedrail use therefore continue to be made in the context of uncertainty, shaped by patient characteristics, organisational culture and medico-legal considerations rather than robust evidence. This review highlights the need for further research using methodologies capable of addressing contextual complexity, ethical tension, and real-world decision making in order to better inform clinical practice and policy. This project contains the following underlying data: Data file 1: Table 1.17 Located in OSF repository. Available from: https://doi.org/10.17605/OSF.IO/GUWDB. License: CC0 1.0 Universal. This project contains the following extended data: Data file 2: Search strategy Medline 06.03.2024.14 Located in OSF repository. DOI: 10.17605/OSF.IO/XEPZM Available from https://osf.io/xepzm/overview?view_only=1f30e453628b45109bfbacd1291f83d7 License: CC0 1.0 Universal. Data file 3: Completed PRISMA ScR checklist adapted from original PRISMA guidelines.10 Located in OSF repository. DOI: 10.17605/OSF.IO/XEPZM Available from: https://osf.io/xepzm/overview?view_only=1f30e453628b45109bfbacd1291f83d7 License: CC0 1.0 Universal. - 1. Medicines and Healthcare products Regulatory Agency. Bed rails: management and safe use 2020 [updated 2023 Aug 30; cited 2024 April 9]. https://www.gov.uk/guidance/bed-rails-management-and-safe-use - 2. Healey F: Bedrails - reviewing the evidence: a systematic literature review. London: National Patient Safety Agency; 2007. https://www.choiceforum.org/docs/nrls.pdf - 3. Shanahan D: Bedrails and vulnerable older adults: how should nurses make 'safe and sound' decisions surrounding their use? Int J Older People Nurs. 2012; 7(4): 272–281. Publisher Full Text - 4. United Kingdom. Medicines and Healthcare products Regulatory Agency. National Patient Safety Alert: Medical beds, trolleys, bed rails, bed grab handles and lateral turning devices: risk of death from entrapment or falls (NatPSA/2023/010/MHRA). 2023 Aug 30. https://www.gov.uk/drug-device-alerts/national-patient-safety-alert-medical-beds-trolleys-bed-rails-bed-grab-handles-and-lateral-turning-devices-risk-of-death-from-entrapment-or-falls-natpsa-slash-2023-slash-010-slash-mhra - 5. Mental Capacity Act 2005 (UK). 2005 c. 9. Updated 2024 May 12. https://www.legislation.gov.uk/ukpga/2005/9/contents - 6. Oliver D: Bed falls and bedrails-what should we do? Age Ageing. 2002 Sept; 31(5): 415–418. Publisher Full Text - 7. Oliver D, Killick S, Even T, et al.: Do falls and falls-injuries in hospital indicate negligent care - and how big is the risk? A retrospective analysis of the NHS Litigation Authority database of clinical negligence claims, resulting from falls in hospitals in England, 1995 to 2006. Qual Saf Healthc. 2008 Dec; 17(6): 431–436. Publisher Full Text - 8. NHS Resolution: Hospital acquired pressure ulcers and falls. Report 3 of 3.London: NHS Resolution; 2022. https://resolution.nhs.uk/wp-content/uploads/2022/03/3-NHS-Resolution-ED-report-Hospital-acquired-pressure-ulcers-and-falls.pdf - 9. World Health Organisation Regional Office for Europe. Regulating medical products. Accessed 2024 Apr 9. https://www.who.int/europe/activities/regulating-medical-products - 10. Tricco A, Lillie E, Zarin W, O'Brien K, Colquhoun H, Levac D, et al.PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation.Ann Intern Med.2018 Oct 2; 169(7): 467–473. Epub 2018 Sep 4. Publisher Full Text - 11. Farrell V, Hall A, Goodwin V: Exploring the use of bed rails in hospitals and the community: a scoping review protocol. OSF. 2024. Updated 2024 Sep 24. https://osf.io/mq56d/files/osfstorage/66f2fec6f0028ef1b2a8522d - 12. Cooke A, Smith D, Booth A: Beyond PICO: the SPIDER tool for qualitative evidence synthesis. Qual Health Res. 2012; 22(10): 1435–1443. Publisher Full Text - 13. Paez A: Gray literature: An important resource in systematic reviews. J Evid Based Med. 2017 Aug; 10(3): 233–240. Publisher Full Text - 14. Farrell V: Exploring the use of bedrails when used to support adults: a scoping review - supplemental data. OSF. 2024 Dec 9. Updated 2026 Jan 15. Publisher Full Text - 15. Ouzzani M, Hammady H, Fedorowicz Z, et al.: Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016 Dec; 5(1):210. Publisher Full Text - 16. Page M, McKenzie J, Bossuyt P, et al.: The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021; 372: n71. Publisher Full Text - 17. Farrell V: Exploring the use of bedrails when used to support adults: Table 1. OSF. 2024. Updated 2026 Jan 15. Publisher Full Text - 18. Noore I, Fleming H, Crowe M, et al.: Use of Cotsides in an Irish Hospital. Ir Med J. 1998; 91: 134–135. https://www.researchgate.net/publication/255568839_Use_of_Cotsides_in_an_Irish_Hospital - 19. Boocock M, Weyman A, McIlroy R: Bedside safety rails: assessment of strength requirements and the appropriateness of current designs. Ergonomics. 2006; 49(7): 631–650. Publisher Full Text - 20. Shanahan D, Evans A: An audit of bedrail use and implications for practice. Br J Nurs. 2009; 18(4): 232–237. PubMed Abstract | Publisher Full Text - 21. Healey F, Cronberg A, Oliver D: Bedrail use in english and welsh hospitals. J Am Geriatr Soc. 2009; 57(10): 1887–1891. Publisher Full Text - 22. Hignett S, Sands G, Fray M, et al.: Which bed designs and patient characteristics increase bed rail use? Age Ageing. 2013 July; 42(4): 531–535. PubMed Abstract | Publisher Full Text - 23. Flatharta T, Haugh J, Robinson S, et al.: Prevalence and predictors of bedrail use in an acute hospital. Age Ageing. 2014 Nov; 43(6): 801–805. Publisher Full Text - 24. Everitt V, Bridel-Nixon J: The use of bed rails: principles of patient assessment. Nurs Stand. 1997 Oct 29-Nov 4; 12(6): 44–47. Publisher Full Text - 25. Huynh D, Lee O, An P, et al.: Bedrails and falls in nursing homes: a systematic review. Clin Nurs Res. 2021 Jan; 30(1): 5–11. Publisher Full Text - 26. Healey F, Oliver D, Milne A, et al.: The effect of bedrails on falls and injury: a systematic review of clinical studies. Age Ageing. 2008 July; 37(4): 368–378. Publisher Full Text - 27. Anonymous. Cotsides - protecting whom against what?Lancet.1984 Aug; 2(8399): 383–384. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(84)90549-X/fulltext - 28. Frengley J: Bedrails: Do They Have a Benefit? JAGS. 1999 May; 47(5). Publisher Full Text - 29. Ali G: Ensuring the safe use of cotsides in patient settings. Prof Nurse. 2000 Jan; 15(4): 278–279. PubMed Abstract - 30. Talerico K, Capezuti E: Myths and Facts About Side Rails. Am J Nurs. 2001 Jul; 101: 43–48. Publisher Full Text - 31. O'Keeffe S: Down with bedrails? Lancet. 2004 Jan 31; 363(9406): 343–344. Publisher Full Text - 32. Marcy-Edwards D: Bed rails. Is there an up side? Can Nurse. 2005 Jan; 101(1): 30–34. PubMed Abstract - 33. Ball M, Hanger H, Thwaites J. Bed rails: a barrier to independence?Clin Rehabil.1997 Nov; 11(4): 347–349. PubMed Abstract | Publisher Full Text - 34. Hanger H, Ball M, Wood L: An analysis of falls in the hospital: Can we do without bedrails? J Am Geriatr Soc. 1999 May; 47(5): 529–531. Publisher Full Text - 35. Si M, Neufeld R, Dunbar J: Removal of bedrails on a short-term nursing home rehabilitation unit. Gerontologist. 1999; 39(5): 611–614. PubMed Abstract | Publisher Full Text - 36. Hoffman S, Powell-Cope G, Mac Clellan L, et al.: Bed SAFE. A bed safety project for frail older adults. J Gerontol Nurs. 2003 Nov; 29(11): 34–42. Publisher Full Text - 37. Capezuti E, Wagner L, Brush B, et al.: Consequences of an intervention to reduce restrictive side rail use in nursing homes. J Am Geriatr Soc. 2007 Mar; 55(3): 334–341. Publisher Full Text - 38. Rubenstein H, Miller F, Postel S, et al.: Standards of medical care based on consensus rather than evidence: the case of routine bedrail use for the elderly. Law Med Health Care. 1983 Dec; 11(6): 271–276. Publisher Full Text - 39. Parker K, Miles S: Deaths caused by bedrails. J Am Geriatr Soc. 1997 Jul; 45(7): 797–802. Publisher Full Text - 40. Todd J, Ruhl C, Gross T. Injury and death associated with hospital bed side-rails: reports to the US Food and Drug Administration from 1985 to 1995.Am J Public Health.1997 Oct; 87(10): 1675–1677. PubMed Abstract | Publisher Full Text | Free Full Text - 41. Capezuti E, Talerico K, Cochran I, et al.: Individualized interventions to prevent bed-related falls and reduce siderail use. J Gerontol Nurs. 1999 Nov; 25(11): 26–34. Publisher Full Text - 42. Brush B, Capezuti E: Historical analysis of siderail use in American hospitals. J Nurs Scholarsh. 2001; 33(4): 381–385. Publisher Full Text - 43. Miles S: Deaths between bedrails and air pressure mattresses. J Am Geriatr Soc. 2002 Jun; 50(6): 1124–1125. Publisher Full Text - 44. Hignett S, Griffiths P: Do split-side rails present an increased risk to patient safety? Qual Saf Health Care. 2005 Apr; 14(2): 113–116. Publisher Full Text - 45. Healey F: Resources for reviewing or developing a bed rail policy. London: National Patient Safety Agency; 2007. https://www.choiceforum.org/docs/nrl.pdf - 46. Kibayashi K, Shimada R, Gen: Accidental deaths occurring in bed: review of cases and proposal of preventive strategies. J Forensic Nurs. 2011 Sep; 7(3): 130–136. Publisher Full Text - 47. Health and Safety Executive. Safe use of bed rails. Accessed 2024 May 3. https://www.hse.gov.uk/healthservices/bed-rails.htm - 48. Morris M, Said C, Haines T, et al.: Reference standard for the prevention and management of hospital falls: a multidisciplinary Delphi consensus study. BMJ Open. 2025; 15(10): e105950. Publisher Full Text - 49. Montero-Odasso M, van der Velde N , Martin F, et al.: World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing. 2022 Sep 2; 51(9): afac 205. Publisher Full Text Author details Author details 1 Cornwall Partnership NHS Foundation Trust, Bodmin, England, UK 2 Faculty of Health and Life Sciences, University of Exeter, Exeter, UK 2 Faculty of Health and Life Sciences, University of Exeter, Exeter, UK Vicky Farrell Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Abigail Hall Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Resources, Software, Supervision, Validation, Visualization, Writing – Review & Editing Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Resources, Software, Supervision, Validation, Visualization, Writing – Review & Editing Victoria Goodwin Roles: Conceptualization, Software, Supervision, Writing – Review & Editing Roles: Conceptualization, Software, Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This project is funded by the National Institute for Health and Care Research (NIHR) under its [‘Research for Patient Benefit (RfPB) Programme’ (Grant Reference Number PB-PG-NIHR305094)]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (3) Copyright © 2026 Farrell V et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. metrics VIEWS $counts.viewCount downloads Citations CITE how to cite this article Farrell V, Hall A and Goodwin V. Exploring the use of bedrails when used to support adults: A scoping review. [version 3; peer review: 1 approved, 1 approved with reservations]. NIHR Open Res 2026, 5:22 (https://doi.org/10.3310/nihropenres.13829.3) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. track receive updates on this article Track an article to receive email alerts on any updates to this article. Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions Version 3 VERSION 3 PUBLISHED 16 Apr 2026 Revised Views 0 How to cite this report: Reynolds S. Reviewer Report For: Exploring the use of bedrails when used to support adults: A scoping review. [version 3; peer review: 1 approved, 1 approved with reservations]. NIHR Open Res 2026, 5:22 (https://doi.org/10.3310/nihropenres.15585.r40366) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-22/v3#referee-response-40366 https://openresearch.nihr.ac.uk/articles/5-22/v3#referee-response-40366 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 20 Apr 2026 Approved VIEWS 0 No ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close No further comments Competing Interests: No competing interests were disclosed. Reviewer Expertise: My area of expertise is previously as a clinician in social care, and as an academic within Occupational Therapy. Research includes the use of Outcome Measures. CITE HOW TO CITE THIS REPORT Reynolds S. Reviewer Report For: Exploring the use of bedrails when used to support adults: A scoping review. [version 3; peer review: 1 approved, 1 approved with reservations]. NIHR Open Res 2026, 5:22 (https://doi.org/10.3310/nihropenres.15585.r40366) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-22/v3#referee-response-40366 https://openresearch.nihr.ac.uk/articles/5-22/v3#referee-response-40366 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. Version 2 VERSION 2 PUBLISHED 13 Mar 2026 Revised Views 0 How to cite this report: Reynolds S. Reviewer Report For: Exploring the use of bedrails when used to support adults: A scoping review. [version 3; peer review: 1 approved, 1 approved with reservations]. NIHR Open Res 2026, 5:22 (https://doi.org/10.3310/nihropenres.15489.r40036) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-22/v2#referee-response-40036 https://openresearch.nihr.ac.uk/articles/5-22/v2#referee-response-40036 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 27 Mar 2026 Approved VIEWS 0 Exploring the use of bedrails when used to support adults: A scoping review. Farrell, V., Hal, A. and Goodwin, V. 1.Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes The ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close 1.Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes The ... Continue reading Exploring the use of bedrails when used to support adults: A scoping review. Farrell, V., Hal, A. and Goodwin, V. 1.Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes The rationale and the objectives for this scoping review was clearly stated. It explored the use of bedrails to support adults in the UK, following the UK Medicines and Healthcare products Regulatory Agency (MHRA) publishing a National Patient Safety Alert (NPSA) in 2023 identifying multiple reports of serious injury and death. This is an important topic, as bedrails are frequently considered as a way to improve patient safety, or are otherwise rejected due to concerns about risk. The introduction noted that as a result of the 2023 NPSA the MRHA mandated that UK organisations involved in using bedrails review their relevant policies and procedures. The methods section noted that the scoping review was informed by concerns raised by concerned family and caregivers about the risks and impact on care provision. This issue prompted the authors to undertake the review aiming to map the evidence and identify gaps for future research. Two reviewers screened the abstracts, following best practice. Minor 1. Links to data files Two and three - Links did not work 2. Definition of the terms Micro, Meso and macro levels- Regarding the terms Micro, Meso and macro levels A few words to explain these concepts in the introductory sentence would make the section on Clinical Drivers for bedrail use may be advised. Meso and Macro are expanded on further in the section though which is helpful. 3. Patient and Public Involvement- It is very good to see PPI, however, it is a little unclear how PPI consultations took place throughout the project, or what capacity family members and caregivers contributed. A little more detail would be useful. 1.Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes The rationale and the objectives for this scoping review was clearly stated. It explored the use of bedrails to support adults in the UK, following the UK Medicines and Healthcare products Regulatory Agency (MHRA) publishing a National Patient Safety Alert (NPSA) in 2023 identifying multiple reports of serious injury and death. This is an important topic, as bedrails are frequently considered as a way to improve patient safety, or are otherwise rejected due to concerns about risk. The introduction noted that as a result of the 2023 NPSA the MRHA mandated that UK organisations involved in using bedrails review their relevant policies and procedures. The methods section noted that the scoping review was informed by concerns raised by concerned family and caregivers about the risks and impact on care provision. This issue prompted the authors to undertake the review aiming to map the evidence and identify gaps for future research. - Are sufficient details of methods and analysis provided to allow replication by others? Two reviewers screened the abstracts, following best practice. - Are the conclusions drawn adequately supported by the results presented in the review? - Yes, the conclusion was adequately supported by the results. It made a strong argument for further research, and suggested methodologies suitable for such a complex real clinical issue. - Is the review written in accessible language? - Yes, it was straightforward to read. I did however wonder if readers may not be familiar with the terms Micro, Meso and macro levels Minor 1. Links to data files Two and three - Links did not work 2. Definition of the terms Micro, Meso and macro levels- Regarding the terms Micro, Meso and macro levels A few words to explain these concepts in the introductory sentence would make the section on Clinical Drivers for bedrail use may be advised. Meso and Macro are expanded on further in the section though which is helpful. 3. Patient and Public Involvement- It is very good to see PPI, however, it is a little unclear how PPI consultations took place throughout the project, or what capacity family members and caregivers contributed. A little more detail would be useful. - Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes - Are sufficient details of the methods and analysis provided to allow replication by others? Partly - Is the statistical analysis and its interpretation appropriate? Not applicable - Are the conclusions drawn adequately supported by the results presented in the review? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: My area of expertise is previously as a clinician in social care, and as an academic within Occupational Therapy. Research includes the use of Outcome Measures. CITE HOW TO CITE THIS REPORT Reynolds S. Reviewer Report For: Exploring the use of bedrails when used to support adults: A scoping review. [version 3; peer review: 1 approved, 1 approved with reservations]. NIHR Open Res 2026, 5:22 (https://doi.org/10.3310/nihropenres.15489.r40036) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-22/v2#referee-response-40036 https://openresearch.nihr.ac.uk/articles/5-22/v2#referee-response-40036 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. Version 1 VERSION 1 PUBLISHED 10 Mar 2025 Views 0 How to cite this report: Okoye SM. Reviewer Report For: Exploring the use of bedrails when used to support adults: A scoping review. [version 3; peer review: 1 approved, 1 approved with reservations]. NIHR Open Res 2026, 5:22 (https://doi.org/10.3310/nihropenres.15024.r35006) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-22/v1#referee-response-35006 https://openresearch.nihr.ac.uk/articles/5-22/v1#referee-response-35006 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 27 May 2025 Safiyyah M. Okoye, Drexel University, Philadelphia, Pennsylvania, USA Approved with Reservations VIEWS 0 This article is a scoping review of the literature that aims to (a) identify and map the current evidence base on the use of bedrails, and (b) identify gaps that may direct future research areas. Overall the article synthesizes findings ... Continue reading 2. Haddaway NR, Collins AM, Coughlin D, Kirk S: The Role of Google Scholar in Evidence Reviews and Its Applicability to Grey Literature Searching.PLoS One. 2015; 10 (9): e0138237 PubMed Abstract | Publisher Full Text I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close This article is a scoping review of the literature that aims to (a) identify and map the current evidence base on the use of bedrails, and (b) identify gaps that may direct future research areas. Overall the article synthesizes findings on this important topic in a way that is digestible and actionable at the micro, meso, and macro levels. The article would benefit from better organization of the Results section, and a revision of the Discussion section that focuses only on discussing and interpreting key findings from the Results section of the review. Another, more minor comment is that there are several areas where more detail is needed in order to ensure comprehension of the article by readers who are not as closely familiar with the topic, as well as international readers. - Are sufficient details of the methods and analysis provided to allow replication by others? - I suggest the authors mention what specific types of gray literature they expected to find using Google Scholar, as this is a limited source of gray literature. The following citations discuss the use of Google Scholar for grey literature searching: Google Scholar and Scopus. J Med Libr Assoc. 2016 (Ref 1). - Haddaway NR, Collins AM, Coughlin D, Kirk S. (Ref 2) - Please include a citation for Rayyan - The article would benefit from better organization of the Results section. While reading the results section I was not easily able to find all the information I needed to interpret the results and I was also not sure of the themes of the narrative report of the results. - I suggest that the authors include Table 1 in body of the manuscript if possible, same as they have included Figures 1 -3. Table 1 is referred to in the text and also seems to be related to Figure 2, but because it is included as a supplementary file it is difficult to navigate to and use as a complement to the text in the results section. - In Figure 2, what are the 3 columns of boxes representing? It is difficult to interpret this diagram. Does it relate to the information provided in the “Clinical drivers for bedrail use” section of the results? Another question is which of the clinical drivers are choices and actions made by organizations vs made by individual clinicians (as mentioned in para 4 of the “Harm” section). Please revise Figure 2 so it stands alone as a figure. - I suggest that the authors include 1-3 sentences in the beginning of the results section to orient to the reader to the themes that will be presented in the section. These themes should then match the subheadings in a logical manner. See below for an example outline of a revised Results section, along with some notes for further clarification: - Overview - Clinical Drivers of Bedrail Use - Framework to understand clinical drivers (figure 2, table 1) - Differences by geographical context: UK and Ireland vs. US - Prevalence of bedrail use – clarify if this is intended to be a report of prevalence in UK and Ireland only, or across the geographic contexts included in the scoping review results - Impact of Bedrail Use - Balance of ethical imperatives - Harm - Behavior change within organizations – might this go in the “clinical drivers section?” - Experience of the user - Alternatives to bedrails – might this go in the “clinical drivers section?" - There are instances in the Discussion section where a topic is discussed that was not adequately reported in the Results section. In general, the discussion section should focus on a few key findings from the review, along with elaboration and interpretation and integration of these findings into the existing literature and discussion of implications of these findings for clinical practice and future research, etc. One example of this is the reference to “paternalistic device” in paragraph 2 of the discussion, as well as in the abstract. In the current version of the article, there is not adequate definition of this term, there is also not a citation to refer the reader to further information, and further this term is not reported in the Results section as a finding in the literature review. I suggest the authors review their results to see if anything related to bedrails as a “paternalistic device” was found, and if so, then in the Discussion section provide a more thorough discussion of this finding. Also, if the authors decide to elaborate, I suggest they tie in how it relates to their findings that some patients wished to use bedrails (as mentioned in paragraph 2 of the “Experience of the user” section). Alternatively, I suggest removing reference to this term from the article. Another topic introduced in the discussion but not mentioned in the Results section was “evidence regarding bedrail use in a person’s own home” (see paragraph 5 of the Discussion section). I suggest the authors comment on the lack of findings in the results section before mentioning this in the discussion. Further, I suggest the authors thoroughly review the remainder of the discussion to ensure that other topics are first introduced in the Results section before the Discussion section. - Introduction - Para 1, please provide examples of moving and handling products for this sentence “…or when bedrails are recommended by the manufacturers of moving and handling products” - Results - Para 1 under UK and Ireland subheading – authors write “In three of the five snapshot audits…” please provide a definition of what an “audit” is, as this was unfamiliar to this reader. - Para 2, under Prevalence of use subheading – please provide examples of advancements in bed technology for this sentence “The authors also expressed concerns that bedrail use is increasing over time, partly due to advancements in bed technology…” - Para 1 under Behavior change within organizations subheading – This sentence was unclear and should be revised “The authors failed to include details in their methodologies, which demonstrated acknowledgement of or control over the variables” - Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes - Are sufficient details of the methods and analysis provided to allow replication by others? Partly - Is the statistical analysis and its interpretation appropriate? Not applicable - Are the conclusions drawn adequately supported by the results presented in the review? Partly

1. Bonato S: Google Scholar and Scopus. Journal of the Medical Library Association. 2016; 104 (3). Publisher Full Text2. Haddaway NR, Collins AM, Coughlin D, Kirk S: The Role of Google Scholar in Evidence Reviews and Its Applicability to Grey Literature Searching.PLoS One. 2015; 10 (9): e0138237 PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Gerontology, nursing CITE HOW TO CITE THIS REPORT Okoye SM. Reviewer Report For: Exploring the use of bedrails when used to support adults: A scoping review. [version 3; peer review: 1 approved, 1 approved with reservations]. NIHR Open Res 2026, 5:22 (https://doi.org/10.3310/nihropenres.15024.r35006) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-22/v1#referee-response-35006 https://openresearch.nihr.ac.uk/articles/5-22/v1#referee-response-35006 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. - Author Response 13 Mar 2026Vicky Farrell, Rehabilitation, Cornwall Partnership NHS Foundation Trust, Bodmin, UK13 Mar 2026Author ResponseOutline The results and discussion section have been revised and re-ordered. Terminology that required clarity such as examples of moving and handling products have been expanded. Definition of grey literature has been expanded and a ... Continue reading Outline The results and discussion section have been revised and re-ordered. Terminology that required clarity such as examples of moving and handling products have been expanded. Definition of grey literature has been expanded and a citation for Rayyan has been added.

The results section has been restructured around five themes identified within the literature: 1. Clinical drivers of bedrail use 2. Prevalence of use 3. The impact and reported harm associated with bedrails 4. The experiences of people involved in decisions about bedrails use 5. Balancing competing ethical imperatives when considering whether to prescribe or withhold bedrails. Table 1 Unfortunately, NIHR Open does not permit addition of Table 1 in the main body of the article and requests that it is in a repository. Snapshot audit Prevalence of bedrail use was most frequently captured using snapshot audits, defined as observational reviews of occupied inpatient beds, conducted at a single point in time, in non-specialist areas of care or in care homes. Data were reported as a binary outcome of either bedrails in use (raised or partially raised) or not in use and findings presented as a percentage of occupied beds using bedrails. Figure 1 and 2. These have been removed. With the revised results and description, they no longer add to the paper.

Comments expanding beyond information identified in the results section have been removed, the term paternalistic has been removed, the discussion should now read much more succinctly and coherently.Outline The results and discussion section have been revised and re-ordered. Terminology that required clarity such as examples of moving and handling products have been expanded. Definition of grey literature has been expanded and a citation for Rayyan has been added.Competing Interests: None Close

The results section has been restructured around five themes identified within the literature: 1. Clinical drivers of bedrail use 2. Prevalence of use 3. The impact and reported harm associated with bedrails 4. The experiences of people involved in decisions about bedrails use 5. Balancing competing ethical imperatives when considering whether to prescribe or withhold bedrails. Table 1 Unfortunately, NIHR Open does not permit addition of Table 1 in the main body of the article and requests that it is in a repository. Snapshot audit Prevalence of bedrail use was most frequently captured using snapshot audits, defined as observational reviews of occupied inpatient beds, conducted at a single point in time, in non-specialist areas of care or in care homes. Data were reported as a binary outcome of either bedrails in use (raised or partially raised) or not in use and findings presented as a percentage of occupied beds using bedrails. Figure 1 and 2. These have been removed. With the revised results and description, they no longer add to the paper.

Comments expanding beyond information identified in the results section have been removed, the term paternalistic has been removed, the discussion should now read much more succinctly and coherently. COMMENTS ON THIS REPORT - Author Response 13 Mar 2026Vicky Farrell, Rehabilitation, Cornwall Partnership NHS Foundation Trust, Bodmin, UK13 Mar 2026Author ResponseOutline The results and discussion section have been revised and re-ordered. Terminology that required clarity such as examples of moving and handling products have been expanded. Definition of grey literature has been expanded and a ... Continue reading Outline The results and discussion section have been revised and re-ordered. Terminology that required clarity such as examples of moving and handling products have been expanded. Definition of grey literature has been expanded and a citation for Rayyan has been added.

The results section has been restructured around five themes identified within the literature: 1. Clinical drivers of bedrail use 2. Prevalence of use 3. The impact and reported harm associated with bedrails 4. The experiences of people involved in decisions about bedrails use 5. Balancing competing ethical imperatives when considering whether to prescribe or withhold bedrails. Table 1 Unfortunately, NIHR Open does not permit addition of Table 1 in the main body of the article and requests that it is in a repository. Snapshot audit Prevalence of bedrail use was most frequently captured using snapshot audits, defined as observational reviews of occupied inpatient beds, conducted at a single point in time, in non-specialist areas of care or in care homes. Data were reported as a binary outcome of either bedrails in use (raised or partially raised) or not in use and findings presented as a percentage of occupied beds using bedrails. Figure 1 and 2. These have been removed. With the revised results and description, they no longer add to the paper.

Comments expanding beyond information identified in the results section have been removed, the term paternalistic has been removed, the discussion should now read much more succinctly and coherently.Outline The results and discussion section have been revised and re-ordered. Terminology that required clarity such as examples of moving and handling products have been expanded. Definition of grey literature has been expanded and a citation for Rayyan has been added.Competing Interests: None Close

The results section has been restructured around five themes identified within the literature: 1. Clinical drivers of bedrail use 2. Prevalence of use 3. The impact and reported harm associated with bedrails 4. The experiences of people involved in decisions about bedrails use 5. Balancing competing ethical imperatives when considering whether to prescribe or withhold bedrails. Table 1 Unfortunately, NIHR Open does not permit addition of Table 1 in the main body of the article and requests that it is in a repository. Snapshot audit Prevalence of bedrail use was most frequently captured using snapshot audits, defined as observational reviews of occupied inpatient beds, conducted at a single point in time, in non-specialist areas of care or in care homes. Data were reported as a binary outcome of either bedrails in use (raised or partially raised) or not in use and findings presented as a percentage of occupied beds using bedrails. Figure 1 and 2. These have been removed. With the revised results and description, they no longer add to the paper.

Comments expanding beyond information identified in the results section have been removed, the term paternalistic has been removed, the discussion should now read much more succinctly and coherently. Alongside their report, reviewers assign a status to the article: - Approved - Approved with reservations - Not approved | Invited Reviewers | || |---|---|---| | 1 | 2 | | | Version 3 (revision) 16 Apr 26 | read | | | Version 2 (revision) 13 Mar 26 | read | | | Version 1 10 Mar 25 | read | Sign up for content alerts You are now signed up to receive this alert Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list: Examples of 'Non-Financial Competing Interests' - Within the past 4 years, you have held joint grants, published or collaborated with any of the authors of the selected paper. - You have a close personal relationship (e.g. parent, spouse, sibling, or domestic partner) with any of the authors. - You are a close professional associate of any of the authors (e.g. scientific mentor, recent student). - You work at the same institute as any of the authors. - You hope/expect to benefit (e.g. favour or employment) as a result of your submission. - You are an Editor for the journal in which the article is published. Examples of 'Financial Competing Interests' - You expect to receive, or in the past 4 years have received, any of the following from any commercial organisation that may gain financially from your submission: a salary, fees, funding, reimbursements. - You expect to receive, or in the past 4 years have received, shared grant support or other funding with any of the authors. - You hold, or are currently applying for, any patents or significant stocks/shares relating to the subject matter of the paper you are commenting on. Sign up for content alerts and receive a weekly or monthly email with all newly published articles Register with NIHR Open Research Already registered? Sign in close Error If you are a previous or current NIHR award holder, sign up for information about developments, publishing and publications from NIHR Open Research. We'll keep you updated on any major new updates to NIHR Open Research Sign In If you've forgotten your password, please enter your email address below and we'll send you instructions on how to reset your password. Email us for further assistance. The email address should be the one you originally registered with F1000. Email address not valid, please try again You registered with F1000 via Google, so we cannot reset your password. To sign in, please click here. If you still need help with your Google account password, please click here. You registered with F1000 via Facebook, so we cannot reset your password. To sign in, please click here. If you still need help with your Facebook account password, please click here. Code not correct, please try again Server error, please try again. If your email address is registered with us, we will email you instructions to reset your password. If you think you should have received this email but it has not arrived, please check your spam filters and/or contact for further assistance. Please wait...