Patients rightfully expect safe care, and healthcare providers strive to deliver care that results in better health and safe, effective outcomes for patients. Unfortunately, events that harm patients do occur while care is being provided, or as a result of that care. While risk is an inherent part of care, we know that many of these events that cause harm can be prevented using current knowledge and practices. (CPSI, 2015).
Patients and families are aware that pressure ulcers are painful and slow to heal; and that ulcers are often seen as an indication of poor quality of care. When caregivers practice the best care every time, patients can avoid needless suffering (IHI, 2012).
The Swans' Story (patient video) (NHS Midlands and East, 2012)
Richard developed an avoidable pressure ulcer during respite at a nursing home. The experience has inspired him, together with his caregiver and wife Doreen, to help inform and educate in the hope that together we can eliminate avoidable pressure ulcers.
Pressure Injury Prevention – Jessie's Story (patient video) (AHS Channel, 2019)
Jessie tells his story of his spinal cord injury leading to his experience with multiple pressure injuries and prevention.
Case Study 1
Healthcare acquired pressure injuries (HIROC 2020)
An elderly patient was admitted to hospital from a nursing home for treatment of lateral ankle pressure injuries. At the time of admission, the patient was assessed to be at low risk for the development of pressure injuries despite risk factors (pre-existing pressure injury, limited mobility, and urinary incontinence). The patient was discharged to the nursing home three weeks later with sacral and heel ulcers. Expert review of the hospital's nurses was not supportive, noting that the team did not complete a skin breakdown assessment, initiate preventive interventions such as a special mattress, use barrier creams, or consult with a nutrition expert or wound specialist. Further, experts were critical of the team's failure to incorporate the patient evolving risk factors into the care plan, including the need for more frequent turning and hydration.