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​Key Changes for Improvement

(IHI, 2011)

Steps for preventing pressure ulcers:

  1. Conduct a pressure ulcer admission assessment for all patients.
  2. Reassess risk for all patients daily.
  3. Inspect skin daily.
  4. Manage moisture on skin.
  5. Minimize pressure, friction and shear:
    1. Turn/reposition patients every two hours.
    2. Use pressure-redistribution surfaces.
  6. Optimize nutrition and hydration.

Additional Elements

  1. Maximize activity and mobility, reducing or eliminating friction and shear (Keast et al., 2006).
  2. Avoid skin massage.
  3. Barrier creams (NICE, 2014).
  4. Emerging therapies for prevention of pressure ulcers:
    • Microclimate control.
    • Prophylactic Dressings.
    • Fabrics and Textiles.
    • Electrical Stimulation of the Muscles for Prevention of Pressure Ulcers (National Pressure Ulcer Advisory Panel, et al., 2014).

Conduct Clinical and System Reviews (see details below)

Given the broad range of potential causes of this clinical group, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

Clinical and System Reviews, Incident Analyses

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.

  2. Use appropriate analytical methods to understand the contributing factors.

  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.

  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for analysis methods are included in Resources for Conducting Incident and/or Prospective Analyses section of the Introduction to the Hospital Harm Improvement Resource.

Chart audits are recommended as a means to develop a more in-depth understanding of the care delivered to patients identified by the HHI. Chart audits help identify quality improvement opportunities.

Useful resources for conducting clinical and system reviews: