Seven Minutes Too Late: The Deadly Risk of Prone Restraints

This episode reviews a malpractice case where a psychiatric patient boarded in an ED for over 24 hours was restrained in a prone position, sedated, and left unmonitored, resulting in cardiac arrest and severe brain injury.

We discuss failures in monitoring, documentation, restraint policies, and the broader problem of psychiatric boarding, plus lessons for clinicians to prevent similar outcomes.

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1. Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document. Western Journal of Emergency Medicine, Vol 20 Issue 5 , July 22, 2019.
2. Resources on Behavioral Health Crowding and Boarding in the Emergency Department (ED) Compiled by members of the ACEP Emergency Medicine Practice Committee, September 2019.