Be aware of pressure ulcer risks

The most commonly reported adverse event remains a pressure ulcer and as more complex patients are admitted to the non-critical care units, the need to document secondary 'at risk' problems becomes more critical— as highlighted in the latest "Reflections on Patient Safety." Please review the most recent installment of this important patient-safety tool that is designed to help close the loop on lessons learned from Focused Event Reviews.

Pressure ulcers are most commonly reported adverse events

Situation: Susan is a teenage girl who was readmitted to the hospital for treatment shortness of breath. Susan has a long history with Children's, having required care multiple times for underlying spina bifida and respiratory distress requiring home BiPAP treatment. Upon admission, the nurse obtained the history and noted that Susan had limited mobility and was in the 50th percentile for weight. The initial skin assessment revealed no skin breakdown and the skin under the BiPAP mask looked free from undue pressure. The nurse did complete the SIRA, or skin integrity risk assessment, that placed Susan in the moderate risk category. Almost immediately, staff had difficulty getting Susan to comply with the standard protocol of turning patients every two hours to avoid development of a pressure ulcer. Due to the moderate risk and health problems, the wound care nurse was consulted and Susan was placed on a pressure-relieving mattress to reduce her risk of developing a pressure ulcer. When staff would return to move Susan, both Susan and her mother would resist turning, stating that she preferred the head of the bed up so that she could use her computer. The plan of care did not reveal that Susan was reluctant to comply. On day 3 of admission, in a routine re-evaluation, the wound care nurse found an unstageable pressure ulcer, a thick scab on top of the skin surface on Susan's buttocks. The wound care nurse discussed the ulcer with Susan and her mother and worked on a plan to keep pressure off the ulcer and increase compliance with the plan to rotate positions to avoid another pressure ulcer.

Background: Data submitted to the Minnesota Patient Safety Registry reveals that the most commonly reported adverse event remains a Pressure Ulcer. The most common gap found for the development of pressure ulcers remains a human factor – Communication. As more complex patients are admitted to the non-critical care units, the need to document secondary 'at risk' problems becomes more critical – as the risk for development of pressure ulcers can remain hidden until the wound requires treatment. Additional risk factors for development of pressure ulcers include respiratory failure, incontinence, poor nutrition and, or diabetes, and neurological or neuromuscular disease.

Assessment: The admitting staff used the SIRA score to assess Susan's risk for developing a pressure ulcer, but under-scored the patient in four areas. This resulted in the higher risk not being communicated immediately to the wound care nurse and delayed initiation of interventions that would reduce the likelihood of developing a pressure ulcer. In addition, staff failed to communicate that the teenager was resisting the standard protocol that would also reduce the likelihood of developing a pressure ulcer – turning the patient every two hours to remove the pressure from one area of the body.

Recommendations: Documentation can improve the communication to all staff who can help prevent a pressure ulcer. Specifically,

1. On the admission assessment, fully assess the skin – "head-to-toe" – for breakdown, engaging the patient and family to point out areas of risk, such as braids or devices. Get assistance from other staff if necessary to complete the initial assessment.

2. Document findings in the IView Integumentary Band. Use the linked SIRA references, if needed, to help score correctly. Skin inspections documentation should include – what you saw, where you saw it, and why is the sore there – this will help guide steps in the discussion with the wound care nurse. If the SIRA score improves, or decreases, verify that the patient's risk for skin issues has been reduced.

3. Communicate the risk and complications associated with pressure ulcers to the family and patient as appropriate. Engaging the patient and family will help in compliance with protocols and aid in early identification of new areas of skin concern or non-compliance.

If you have feedback regarding this or any "Reflections on Patient Safety" story, or to recommend a story for inclusion in a future edition, please contact Pam Graves, RN, CNP, FHIMSS, clinical quality and safety improvement consultant, Center for Quality and Safety at This e-mail address is being protected from spambots. You need JavaScript enabled to view it.