RESTRAINT MINIMISATION & SAFE PRACTICE -
Policy 1.2.4
REPORTING
Protocol 3
RESTRAINT
PROTOCOL
STANDARD
When to complete an online Incident Management Form
Restraint initiated on patient
No
Was consent given?
Yes
Is the intention to prevent hard
Is this part of normal
and/or administer treatment?
care plan / procedure?
Yes
Yes
This is Restraint
Is the intention to
promote safety and/or
independence?
Complete an on-line Incident
Management form
Yes
This is an Enabler
Ful y document in patient’s
health record
No Incident Management
form required
.
If injury or adverse effect
occurs an on-line Incident
Management form is to be
Document in patient’s generic
completed
Careplan and/or Falls Risk
Careplan
Issue Date:
May 2017
Page 1 of 3
NOTE: The electronic version of
Review Date: May 2020
Version No: 7
this document is the most current.
Any printed copy cannot be
Protocol Steward: Restraint
Authorised by: Director of Nursing
assumed to be the current version.
Co-ordinator
RESTRAINT MINIMISATION & SAFE PRACTICE -
Policy 1.2.4
REPORTING
Protocol 3
RESTRAINT
PROTOCOL
The following situations do not require clinical staff to complete an Incident Management
form:
Any patient who is under the jurisdiction of the Police or a prison officer and is being
detained by them.
Any person who is not a patient and is being escorted from the hospital property by the
Police or Security (Incident Management form only if Security or a member of the DHB
staff are involved)
What Happens to the Incident Management Form?
Form is completed on-line by
Restraint Leader
Mental Health & Addiction
Results are automatically
Restraint Minimisation
Services review all restraint via
recorded into the Incident
Co-ordinator evaluates
Inpatient Clinical Governance
Management system
completed on-line form
Monthly meetings
Restraint Minimisation
Practice of Restraint Advisory
Co-ordinator to liaise with area
Group (PRAG) informed of
Advisor / Nurse Leader /
restraint incidents on a 3-
Midwife Leader
monthly basis
Restraint Minimisation
Database results reviewed to
Co-ordinator to initiate further
identify any trends or areas of
training / ward inservices, if
concern
required
Summary of PRAG meeting
minutes to Performance &
Environment Committee
Issue Date:
May 2017
Page 2 of 3
NOTE: The electronic version of
Review Date: May 2020
Version No: 7
this document is the most current.
Any printed copy cannot be
Protocol Steward: Restraint
Authorised by: Director of Nursing
assumed to be the current version.
Co-ordinator
RESTRAINT MINIMISATION & SAFE PRACTICE -
Policy 1.2.4
REPORTING
Protocol 3
RESTRAINT
PROTOCOL
ASSOCIATED DOCUMENTS
Bay of Plenty District Health Board Restraint Minimisation & Safe Practice controlled
documents
Bay of Plenty District Health Board policy 0.0 Glossary of Terms / Definitions
Bay of Plenty District Health Board policy 1.1.1 Informed Consent
Bay of Plenty District Health Board policy 2.1.1 Risk Management
Bay of Plenty District Health Board policy 2.1.2 protocol 2 Controlled Document
Development Standards
Bay of Plenty District Health Board policy 2.1.2 protocol 6 Controlled Document Review
Standards
Bay of Plenty District Health Board policy 2.1.3 Hazard Management
Bay of Plenty District Health Board policy 2.1.4 Incident Management
Bay of Plenty District Health Board policy 5.4.7 Threatening Behaviour, Bullying,
Harassment and Violence in the Workplace - Management
Bay of Plenty District Health Board policy 7.104.1 protocol 3 Care Delivery – Observing
Patients
Bay of Plenty District Health Board Practice of Restraint Advisory Group (PRAG) Terms
of Reference
Bay of Plenty District Health Board Incident Management Form
Issue Date:
May 2017
Page 3 of 3
NOTE: The electronic version of
Review Date: May 2020
Version No: 7
this document is the most current.
Any printed copy cannot be
Protocol Steward: Restraint
Authorised by: Director of Nursing
assumed to be the current version.
Co-ordinator