Given the broad range of potential causes of hospital associated Pressure Ulcers, clinical and system reviews should be conducted to identify latent causes and determine appropriate recommendations.
Occurrences of harm are often complex with many contributing factors. Organizations need to:
- Measure and monitor the types and frequency of these occurrences.
- Use appropriate analytical methods to understand the contributing factors.
- Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
- Have mechanisms in place to mitigate consequences of harm when it occurs.
To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for
conducting chart audits and
analysis methods are included in the
Hospital Harm Improvement Resources Introduction.
If your review reveals that your cases of Pressure Ulcer/Injury are linked to specific processes or procedures, you may find these resources helpful:
- Agency for Healthcare Research and Quality (AHRQ)
- British Columbia Provincial Nursing Skin and Wound Committee.
- Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury: A Resource Handbook for Clinicians
- National Pressure Injury Advisory Panel
- Black JM, Edsberg LE, Baharestani MM, et al. Pressure ulcers: Avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference.
Ostomy Wound Manage. 2011;57(2):24-37.
- National Pressure Injury Advisory Panel. NPIAP COVID-19 Related Resources for Pressure Injury Prevention. Published April 2, 2020.
- Munoz N, Posthauer ME, Cereda E, Schols JMGA, Haesler E. The Role of Nutrition for Pressure Injury Prevention and Healing: The 2019 International Clinical Practice Guideline Recommendations.
Adv Skin Wound Care. 2020;33(3):123-136. doi:10.1097/01.ASW.0000653144.90739.ad
- NICE National Institute for Health and Care Excellence
- Registered Nurses Association of Ontario