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Publication Type: OBS Messages
Single or Multiple Incident: Multiple
Date: 10/22/2009 12:00:00 AM
Country: Denmark

This alert discusses the potential patient safety incidents of pressure ulcers developing when pressure ulcer prevention mattresses and pillows are used incorrectly. Two incidents are described, one of a hospitalized patient and one home care client. Strong pressure on the skin as a result of incorrect or lack of pressure relief can – even after a short time – lead to the client or patient developing pressure ulcers. In addition, adverse events of this type can cause healing to be delayed and existing pressure ulcers to worsen. The alert provides recommendations on the appropriate use of mattresses and seat cushions.

Additional Details

Device:
pressure ulcer prevention mattress, pressure ulcer prevention pillows, seat cushions, pressure-relieving pad


Improper operation of pressure ulcer prevention mattresses and pillows