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Pressure Ulcer Root Cause Analysis

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Root Cause Analysis For Hospital

NPUAP’s Root Cause Analysis (RCA)

Black JM. Root Cause Analysis for Hospital-Acquired Pressure Injury. J Wound Ostomy Continence Nurs. 2019 46:298-304. doi:10.1097/WON.0000000000000546

Pressure injuries are a persistent problem in health care. This article describes a three-level root cause analysis approach to determine physical, process, and systems factors that contribute to the occurrence of this never event. The author suggests that common cause analysis is an effective method to utilize root cause analysis results to determine latent weaknesses that facilitate pressure ulcer development.

Immobility As The Root Cause Of Pressure Ulcers

Many factors can contribute to the formation of a pressure ulcer, but its rare that one develops in an active, mobile patient. As the National Pressure Ulcer Advisory Panel 2014 guidelines state, Pressure ulcers cannot form without loading, or pressure on the tissue. Extended periods of lying or sitting on a particular body part and failure to redistribute the pressure can lead to ischemia and therefore tissue damage. Thus, immobility is frequently the root cause of pressure ulcer development.

As clinicians, we need to assess all patients for immobility and address the source. The goal is to modify, stabilize, or eliminate the cause of the immobility.

Ensure Appropriate Footwear At All Times

Be sure socks and shoes fit properly. Socks shouldnt be too tight or too loose, which could lead to slipping and subsequent friction, causing skin injury. Ensure that shoe soles arent slippery. If the patient shuffles when he or she walks, soles need to accommodate this characteristic without excessive slipperiness.

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Identifying Root Causes And Solutions For Hospital Acquired Pressure Injuries


  • Pain
  • Increased length of institutional stay
  • Premature mortality

Multi-Hospital InitiativeRobust Process ImprovementPrevalence in the ICU

  • Completing a project charter defining the business case, problem statement, dates, scope, and goals
  • Refining the project scope to the unit with the highest percentage of HAPIs the intensive care unit
  • Mapping the processes so that it was clear to all team members what is happening today , and how it contributed to a reduction in HAPU/Is
  • Building core teams who will do the project work and investigate the root causes, including the subject matter experts
  • ICU HAPU/I rates: based on monthly patient surveys of the ICU to identify HAPIs in the ICU
  • AHRQ/PSI-03 HAPI rate rate of hospital acquired pressure injuries measured by EMR codes and discharge counts to identify hospital wide HAPIs as CMS defines them
  • Unit acquired pressure injuries to identify for those HAPIs in the ICU, how many patients did not have an ICU before arrival on the unit
  • Collecting Data

    • How often does each patient receive a comprehensive skin assessment within 24 hours? How do we know?

    Michael King is a Lean Six Sigma Black Belt at The Joint Commission. Prior to this position, he worked in process improvement at Nielsen Company, Menlo Worldwide and a variety of engineering firms.

    Evaluation Of The Suitability Of Root Cause Analysis Frameworks For The Investigation Of Community

    (PDF) Pressure ulcer

    Caroline McGraw BSc , MSc, PhD, RN, PGDip


    City University, London, UK

    Correspondence: Caroline McGraw, Lecturer, School of Health Sciences, City University, 20 Bartholomew Close, London, EC1A 7QN, UK. Telephone: +44 20 7040 5922.

    Vari M Drennan BA , MSc, PhD, RN, RHV

    Professor of Health Care and Policy Research

    St George’s University of London, London, UK

    Caroline McGraw BSc , MSc, PhD, RN, PGDip


    City University, London, UK

    Correspondence: Caroline McGraw, Lecturer, School of Health Sciences, City University, 20 Bartholomew Close, London, EC1A 7QN, UK. Telephone: +44 20 7040 5922.

    Vari M Drennan BA , MSc, PhD, RN, RHV

    Professor of Health Care and Policy Research

    St George’s University of London, London, UK

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    Going Beyond The Basics

    Clinicians typically respond to immobility with interventions designed to minimize the pressure. Interventions might include pressure redistribution products for the bed and wheelchair, elevation of the heels off the bed, and an aggressive turning and repositioning program for the patient.

    Although these interventions are appropriate and consistent with standards of practice, we must take the next step by ensuring our patients are moving as much as possible. We need to consult with occupational and physical therapists and tap into restorative nursing programs to help keep patients more active. Strategies include an exercise program that promotes strengthening, balance, stability, and endurance through such activities as lifting weights, tai chi, agility courses, pre-Pilates, boxing, walking, and kayaking.

    Here are some tips for encouraging mobility.

    Ahrq’s Safety Program For Nursing Homes: On

    The Self-Assessment Worksheet is designed to help staff review how they currently identify residents who have experienced a change in pressure ulcer risk, how they determine if new clinical interventions are needed, and how they determine what those interventions are. The self-assessment tool is intended to help identify the current processes and structures the nursing home uses to prevent pressure ulcers and identify gaps and places for improvement. It is intended to help staff think about ways to transform these processes and how to begin to use the pressure ulcer prevention reports in clinical discussions. The self-assessment tool is an important first step in implementing the reports into current workflow.

    The team is expected to use the Self-Assessment Worksheet to help understand current pressure ulcer prevention practices. This is the first step to help them determine how to transform their current practices and to identify ways to incorporate the On-Time Reports into current practice. It is expected that the facilitator will work with the change team to identify gaps in current pressure ulcer prevention practices and help them see ways to incorporate the reports to improve these practices and improve clinical interventions.

    The Self-Assessment Worksheet shows how the nursing home:

    The Self-Assessment Worksheet has four sections:

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    Root Cause Analysis Toolkit

    For facilities that are new to conducting root cause analysis – and even for those who are more experienced – it can sometimes be difficult to establish a process that runs smoothly, is comfortable for participants, and leads to meaningful, focused discussions of system issues that may have contributed to events. This online RCA toolkit is designed to be a resource for any facility that would like to establish or improve their RCA process. It contains sample policies, position descriptions and agendas, graphic organizers and visual aids, question guides, invitations and ground rules, case studies and other documents that facilities can use to educate their staff, their RCA facilitators, or their leaders about this process. You are welcome to make use of anything in this toolkit, or to adapt it for your own purposes. Where appropriate, please cite the organization that is the source of the tool.

    This toolkit will evolve and change over time, as we become aware of new tools and resources that may be helpful. If you have documents or resources that you would like to contribute, please email them to Rachel Jokela at

    Use Equipment As Needed To Promote Mobility

    Pressure Ulcers Patho Disease Presentation

    Grab bars on the bed help promote movement in the bed as well as safe egress and transfers. Keep the height of the bed at the point where the patients feet can touch the floor when he or she is sitting on the side of the bed and the bend at the knee is just slightly higher than 90 degrees. Use sit-to-stand or ceiling lifts to promote mobility. And remember the basics, such as properly fitted walkers and canes, grab bars in the bathroom, and an appropriate toilet seat height.

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