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Publication Type: Patient Safety Alert
Single or Multiple Incident: Multiple
Date: 3/9/2021 12:00:00 AM
This alert addresses the increase in pressure injuries submitted in 2020. Pressure injuries accounted for 12% of 2020 hospital reports, including two reports related to COVID-19 patients in prone position. Common themes among the causes identified by hospital reporters during their adverse event investigations were found: • Documentation or communication issues • Missed or incomplete inspections or assessments • Complex patient comorbidities The alert provides a number of resources to support organizations in their strategies to prevent pressure injuries and a recommendation to address this adverse event.


Rules / Policies / Procedures
  1. While pressure injuries can be difficult to prevent, quality improvement techniques can help healthcare facilities identify what might be causing them, implement best practices, track improvement, and ensure consistent use of best practices over time.

Increase in Pressure Injuries Reported in 2020: What We Are Learning