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Single or Multiple Incident: Single
Date: 10/1/2017 12:00:00 AM
Country: Canada
Organization: Manitoba Health
This alert identifies a patient safety incident of development of a stage 3 pressure injury in a long term care resident. Contributing factors included only partial implementation of the Pressure Injury Prevention and Treatment guideline for wound care management. Recommendations included routine multidisciplinary safety huddles for patients/residents assessed to be at risk for the development of a pressure injury.


Rules / Policies / Procedures
  1. Revise the Pressure Injury Prevention and Treatment Guideline to include the multidisciplinary team pressure ulcer safety huddle for patients/residents assessed to be at risk for the development of a pressure injury.
Training
  1. Re-educate health care providers on the revised Pressure Injury Prevention and Treatment Guideline, which focuses on prevention of these injuries by ensuring all supporting documents are appropriately completed.

Pressure Injury