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Root Cause Analysis (RCA) of Pressure Ulcer Development Hot

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Area Classification

Acute / Hospital Care

Briefly describe what it is

RCA is conducted on every patient that develops a pressure ulcer in Ipswich Hospital with the purpose of identifying the cause and instigating changes in practice which in turn reduces occurrence. The analysis considers key elements and contributory factors that are prevalent in pressure ulcer development during the patient’s journey. Analyses include timely risk assessment and review, equipment supply and appropriateness, nutritional status and intervention, care delivery and intervention, therapeutic interventions, mobility and mood status. Once completed, staff in the area and other appropriate clinical staff, review the RCA and develop recommendations.

Were there any key things that you had to do to make it happen?

Key elements were staff engagement, education, documentation development, and monitoring. The programme was rolled out using a PDSA cycle, with one ward piloting the documentation and process. Training and support was provided and other clinical areas were introduced in a managed staged process until all were participating

Describe (and provide evidence) of the impact on quality of care

Critically analysing the RCA’s enables measurement of the quality of our pressure ulcer prevention efforts trust wide. When comparing April–September 2009 with the period April –September 2008 there has been a reduction of pressure ulcer development of 22% (36 patients).

Describe (and provide evidence) of the impact on patient (or staff) experience

There has been a heightened awareness of the issues surrounding pressure ulcer development which in turn has focused care delivery. Strength of the process is that the RCA is discussed by staff directly caring for patient, developing an ownership mindset within the team of ‘How can we do better?’

Describe (and provide evidence) of the impact on reducing cost

The minimum cost of Grade 2 pressure ulcer is £3948* per episode and a 50% reduction demonstrates a minimum saving of £323,736 (82 patients).

Keywords / Tags

Pressure Ulcers RCA

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