Pressure injury prevention is no simple task. It requires a team of care providers across multiple disciplines coordinating highly structured prevention practices that are also tailored to the individual patient needs and their risk factors. We noticed that in 2020 hospitals submitted more pressure injury reports to the Patient Safety Reporting Program (PSRP) than in previous years, so we decided to take a closer look at what they’re learning. Pressure injuries accounted for 12% of 2020 hospital reports, including two reports related to COVID-19 patients in prone position. We found some common themes among the causes identified by hospital reporters during their adverse event investigations.

• Documentation or communication issues

• Missed or incomplete inspections or assessments

• Complex patient comorbidities

What You Can Do

While pressure injuries can be difficult to prevent, quality improvement techniques can help healthcare facilities identify what might be causing them, implement best practices, track improvement, and ensure consistent use of best practices over time. All of the solutions proposed by hospital reporters in their 2020 pressure injury reports were aligned with best practices recommended by experts like the National Pressure Injury Advisory Panel (NPIAP).

Resources that Can Help

Preventing Pressure Ulcers in Hospitals
An AHRQ toolkit to implement a pressure injury prevention practices through an interdisciplinary approach.

Impact of a Pressure Injury Prevention Bundle in the Solutions for Patient Safety Network
A 2017 Pediatric Quality and Safety article about how the Children’s Hospitals Solutions for Patient Safety Network significantly reduced stage 3 and 4 pressure injuries.

Value of Hospital Resources for Effective Pressure Injury Prevention: A Cost-Effectiveness Analysis
A BMJ Quality and Safety article that demonstrates pressure injury prevention can be cost effective.

NPIAP Covid-19 Related Resources for Pressure Injury Prevention
A collection of resources shared by the National Pressure Injury Advisory Panel (NPIAP).

Pressure Injury Prevention Tips for Prone Positioning
A NPIAP pressure injury prevention tip sheet that includes information for COVID-19 patients, among general prevention tips.