Iran Journal of Nursing

Introduction
Hospitalized incarcerated patients are usually handcuffed during their treatment in medical facilities to prevent them from escaping and harming others or themselves. Despite the little information about the benefits of handcuffing incarcerated patients in the hospital, there is considerable information about their physical harm to the patient and commit suicide. It is important to pay attention to these concerns. Incarcerated patients are one of the vulnerable groups due to being in special physiological, physical, psychological, social conditions and may be at greater risk  compared to other patients when receiving care, diagnosis and treatment services. Considering the benefits that the use of handcuff wrist protectors has had on the statistics related to hospital safety and accreditation programs, this study aimed to report the effectiveness of designed hand/leg cuff protectors for incarcerated patients.

Methods 
This is quality improvement report. The plan of using hand/leg cuff protectors for incarcerated patients was implemented by the Iran Psychiatric Hospital in 2019. The protector is placed on the wrist or leg and under the hand/leg cuff to prevent possible injuries to the patient. Using the statistics related to safety and accreditation in the quality improvement office of the hospital from 2012 to 2022 (including the statistics of hospitalized prisoners, the failure mode and effect analyses (FMEA) results of the committee for finding errors in the hospital, the accident forms data, the used consumables following injury by handcuffs during hospitalization), we analyzed the data before and after the implementing the plan for prisoners hospitalized in the Iran Psychiatric Hospital.

Results
The results of comparing the data before and after using the hand/leg cuff protectors showed that the intervention reduced the number of consumable items in the hospital and the value of indicators related to safety and errors in hospitalized prisoners. The risk priority number reduced from 125 to 8; the number of used bandages reduced from 38 to zero; and the incidence of wounds reduced from nine to zero. Also, according to the Prisons Department report, the prisoners were satisfied with the hand/leg cuff protectors. Also, it led to the entrepreneurship of women to produce and sew these protectors. 

Conclusion 
According to the findings, the use of hand/leg cuff protectors had a significant impact on reducing injury rates in incarcerated patients admitted to the Iran Psychiatric Hospital. According to the statistics of the quality improvement office, there was a decrease in the incidence of wounds caused by the cuffs, risk priority number, and used consumable items. This is in line with the principles and goals of Iran University of Medical Sciences, which is based on maintaining human dignity, rule of law, justice in health provision, community participation, and satisfaction of patients, continuous improvement of service quality, and increase in productivity. On the other hand, our results are in line with the goals of accreditation plan for improving integration in the management of health services, reducing risks for patients and staff, providing training and counseling to health centers, and reducing costs. Therefore, psychiatric centers and other medical centers are recommended to use the designed hand/leg cuff protectors for their incarcerated patients.

Ethical Considerations
Compliance with ethical guidelines
All ethical principles were considered in this study. No experiments on human or animal samples were conducted in this study. Therefore, no ethical code was obtained.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors.

Authors' contributions
Conceptualization and investigation: Fereshte Ghasemi and Malihe Ranjbar; Data analysis: Zahra Talebnia; Editing & review, project administration: Fereshte Ghasemi

Conflict of interest
The authors declare no conflicts of interest. 

Acknowledgments
The authors would like to thank Dr. Mr. Poursamaei (the president of the Iran Psychiatric Hospital), and Dr. Keshavarz Akhlaghi (the Iran Psychiatric Hospital manager) for their support and assistance in this study. 

References

1. Haber LA, Pratt LA, Erickson HP, Williams BA. Shackling in the hospital. J Gen Intern Med. 2022; 37(5):1258-60. [DOI:10.1007/s11606-021-07222-5]
2. Fovet T, Amad A, Horn M, Thomas P, Chan-Chee C. Utilization of hospital-level mental health care services for inmates in France: A transversal study. Psychiatr Serv. 2020; 71(8):824-828.  [DOI:10.1176/appi.ps.201900497] [PMID]
3. Scarlet S, Dreesen EB. Delivering hospital-based medical care to incarcerated patients in North Carolina state prisons: A call for communication and collaboration. North Carolina Med J. 2019; 80(6):348-51. [DOI:10.18043/ncm.80.6.348]
4. Haddad F, Goddard N, Kanvinde R, Burke F. Complaints of pain after use of handcuffs should not be dismissed. BMJ. 1999; 318:55. [DOI:10.1136/bmj.318.7175.55]
5. Haber LA, O’Brien M. Shackling ulcer: An upper extremity ulcer secondary to handcuffs. J Gen Intern Med. 2021; 36(7):2146. [DOI:10.1007/s11606-021-06654-3]
6. Brooks KC, Makam AN, Haber LA. Caring for hospitalized incarcerated patients: Physician and nurse experience. J Gen Intern Med. 2021; 37:485–7. [DOI:10.1007/s11606-020-06510-w]
7. Nasiripour AA, Jafari S. [The relationship of quality improvement and patient safety with performance indicators in Shahid Beheshti University of Medical Science teaching hospitals (Persian)]. Payavard Salamat. 2016; 10(4):311-9. [Link]
8. Farup PG. Are measurements of patient safety culture and adverse events valid and reliable? Results from a cross sectional study. BMC Health Serv Res. 2015; 15(1):1-7. [DOI:10.1186/s12913-015-0852-x]
9. Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian adverse events study: The incidence of adverse events among hospital patients in Canada. CMAJ. 2004; 170(11):1678-86. [DOI:10.1503/cmaj.1040498]
10. Gharaee H, Jahanian R, Hosseini Karim M, Kakemam E, Bande Elahi K, Tapak L, et al. Relationship between patient safety culture and adverse events in hospital: A case study. J Health Adm. 2020; 23(1):13-26. [DOI:10.29252/jha.23.1.13]
11. Cooper MD. Towards a model of safety culture. Saf Sci. 2000; 36(2):111-36. [DOI:10.1016/S0925-7535(00)00035-7]
12. Pakdaman M, Geravandi S, Kiqbadi N, Ismail M. [The relationship between quality improvement and patient safety with performance indicators in teaching hospitals of Yazd University of Medical Sciences (Persian)]. J Manage Med Inf Sch. 2018; 3(3):14-23. [Link]
13. Javadi M, Karimi S, Behzadnezhad MM, Bayat P. [Status of incident reporting system in Iranian hospitals: A national survey (Persian)]. J Mil Med. 2022; 22(9):947-55. [DOI:10.30491/JMM.22.9.5]
14. Kolich M. Using failure mode and effects analysis to design a comfortable automotive driver seat. Appl Ergon. 2014; 45(4):1087-96.  [DOI:10.1016/j.apergo.2014.01.007] [PMID]

15. Ibrahim A, Abdalla SM, Jafer M, Abdelgadir J, De Vries N. Child labor and health: A systematic literature review of the impacts of child labor on child’s health in low-and middle-income countries. J Public Health. 2019; 41(1):18-26. [DOI:10.1093/pubmed/fdy018]
16. Ghadiri M, Rasoulian M. [History of Iran psychiatry hospital (Persian)]. Iran J Psychiatry Clin Psychol. 2017; 23(1):118-25. [DOI:10.18869/nirp.ijpcp.23.1.118]
17. Handcuff Warehouse. Neoprene Wrist/Ankle Protectors Virginia: Handcuff Warehouse; 2022. [Link]
18. Patrician PA, Brosch LR. Medication error reporting and the work environment in a military setting. J Nurs Care Qual. 2009; 24(4):277-86. [DOI:10.1097/NCQ.0b013e3181afa4cb]
19. Yousefian M, Eyni S, Amini K, Ershadifard S, Gheybati F, Asadi H. [The status of patient safety culture in Iranian hospitals: A systematic review (Persian)]. Payesh. 2023; 22(2):129-38. [DOI:10.52547/payesh.22.2.129]
20. Hassanzadeh E, Daastari F, Soltani Z, Sheikhy-Chaman M. [The impact of accreditation on the quality of hospital services from the perspective of nurses in Tehran (Persian)]. Nurs Midwifery J. 2021; 18(10):805-795. [Link]