An 88-year-old male patient wrs found on his hands and knees on the floor beside his bed. The bedrails were up."-From an indent reporr fikd b-j a nurse at the Stillman Infirmary, University Health Sovices, Haward Uniuersity, in May 1980. F inding elderly patients lying on the floor beside their beds despite the presence of elevated bedrails seems paradoxical: how can a patient fall out of bed when the bedrails are up? Surprisingly, this paradox constitutes one of the leading incidents plaguing hospitals in the United States today.' It exemplifies a much larger problem created, we believe, by the uncritical adoption of measures designed to enhance patient welfare, but which may in fact undermine it. This article documents our ~~~ ~~Dr. Rubenstein is Physician and Chiefof the Allergy Clinicat University Health Services at Hanvlrd Uniwrsity in Cmnbndge, Masahusetts. Ms. Miller is Profemr of Law at Boston University School o f h w , in Boston, Marsachusetts. Dr. Postel is Deputy Director, Chief of Professional services, and Chief of Medicine at Uniuersity Health Services of Haward Uniuersity. Ms. Euam is Superuisor of the Inpatient Nursing Service, Stillman hfirmau, Qt University Health Services of Harvard Uniwrsity. The authors greatly appreciate the mistance provided by the Committee on Qualio Assurance and Utilization Rwiw at Haward's University Health Seruues; Judith S. Rubewein, Ed.D., educational comltanr; and the nurses of Stillman Infirmary.

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