Clinical Scenario related to Patient Safety:
A frail patient, aged 84, with a history of falls, was admitted via Accident and Emergency with respiratory problems for which he was treated with Intermittent Positive Pressure Ventilation.  He was taken directly to the Intensive Care Unit where he was ventilated overnight.  His intubation was removed the next morning and he was subsequently transferred to the ward at 19.00 hours.  The Ward was busy but after visiting their relative, the patients family asked for bedrails to be put in place and this was carried out.  At 03.00 hours the patient was found to be lying on the floor and he suffered a fractured hip and subsequently died 2 days later.