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Using Patient safety Investigations to reduce Pressure ulcers Incidence Hot

User rating
4.0 (1)


Area Classification

Acute / Hospital Care

Briefly describe what it is

Introduction of patient safety investigations for grade 3 and 4 pressure ulcers in order to identify the route cause. The results of the investigation are presented to the chief nurse, and at a quality review meeting with ward representatives. In order to share learning.

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

Support from the Chief nurse.
Education of the Tissue Viability team in able to support and fascilitate the process.
Training for ward teams (provide as part of the Trust patient safety approach.

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

Learning from each incidence has been shared and impacted on the care of patients throughout the hospital. Since the introduction of this appraoach greade 3 and 4 pressrue ulcers has reduced by 1/3 and we are working towards a 50% reduction on last years reported incidence.

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

The most severe pressure ulcers may threaten both limbs and life, quality of life is compromised with pain and discomfort. While the idividual may not benefit from the learning other patients experience is improved through reduction of pressure ulcers

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

A grade 4 pressure ulcer could cost up to £40,000 to treat, the average expected cost being approximatly £14,000 per episode. Pressure ulcers cost between £1.9 and 2.8 Billion each year. A reduction of 1/3 in grade 3 and 4 would therefor save the UK £240,000 approximatly

Keywords / Tags

pressure ulcer. patient safety

User comments


Root Cause Analysis

This is a very similar approach to that used in my organisation.

The Lead Tissue Viability Nurse in our organisation deveoped a RCA investigation process as part of her MSC project that is now used Trustwide for all Garde 3 and 4 pressure ulcers.

An RCA is triggered by the ward were the pressure ulcer is identified and a Matron led investigation is then completed in conjunction with the staff involved in the care of the patient, ofetn more than one clinical area.

A meeting is convened and attended by the Director of Nursing, Tissue Viability Nurse, Senior Sister/s and Matron/s as well as a nurse from eah area directly involved in provision of care to the patient.

The investigation report is then reviewed and areas of good practice acknowledged and areas of poor practice or ommissions discussed and rationale sought from the direct care givers and Senior Sister.

An action plan is developed and follow up review scheduled for 6 months later.

Any areas that have repeated RCA's triggered are then investigated further to identify if their are system failures that need to be improved/developed through support and learning.

To date we have seen a reduction in pressure ulcers but feel more improvement is needed. Staff feedback is that practice changes as a result of the RCA meeting as it often helps staff to understand their accountability and responsibility to provide quality care to patients.
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