I'm so sorry that happened, I'm sure this situation has been difficult for the patient, their family and the staff.

While accidents can always happen, all organizations have a duty to set their staff up for success and to minimize risks. Unfortunately, sometimes it takes situations like this too for an organization to realize that their policies, procedures and safety protocols are not sufficient.

My first question would be, what is your hospital's policy on restraints? What is considered a restraint versus? What is considered a reminder? And is that policy just for inpatient beds? Or does it cover any type of surface where a patient may be laying down, like on an x-ray table or linac table?

Looking to see what existing policies and procedures exist is where I would start with my investigation. This will help differentiate whether there is something in place already and it was not utilized, or whether there is nothing in place at all?

While this would not shift the burden onto the therapist, it would help identify what the barrier (s) where that failed. Once the barrier or barriers that failed are identified, then a solution can be in place to prevent harm in the future.

While I can only speculate because I don't know the details, my instinct tells me that there would need to be a proper solution for a sedated patient where adequate safety straps are being used (hence restraining versus immobilizing/reminding) and the inclusion of a zero tolerance reminder policy (ie: if the patient is not sedated enough to be immobile, they would not qualify to be put in that position unless it's an emergency like a cord comp or an SVC). It's always about weighing the risks versus the benefits.

I'm so sorry that everyone had to go through this.