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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.

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