PURPOSE: Using event reporting to determine the root cause(s) of nosocomial pressure ulcers as a basis for staff-development and unit-based quality improvement programs. OBJECTIVE: Perfect the nursing staff's use and accuracy of the Braden's Scale for pressure ulcer risks and improve communications at the unit/department level regarding patients who are at high risk for pressure ulcers. PROBLEM: Our 250-licensed bed community hospital participates in the quarterly reporting of hospital-acquired pressure ulcer prevalence and incidence to the National Database of Nursing Quality Indicators (NDNQI). The data analysis from NDNQI shows comparative information from other participating hospitals nationwide. It does not, however, identify the root cause of the nosocomial pressure ulcer incidence within our hospital. NDNQI does not reflect the process of where the problem exists. Therefore, is there another reporting process that could mirror the NDNQI data collection and give us information that is more definitive? SOLUTION: The hospital began a program requiring that for every nosocomial pressure ulcer identified by the WOCN, an event report would be completed by the staff nurse and submitted to the Quality Assessment department for review. The event reports include specific data as to the cause and effect that would require further follow-up investigation. OUTCOME: A retrospective study of reviewing event reports with identified hospital-acquired pressure ulcers from 2005 will be used to determine where the quality improvement processes need to be focused. The data analysis will establish additional benchmarking. This data will be used to reduce the incidence and severity of nosocomial pressure ulcers by improving the use and accuracy of the Braden Scale by the nursing staff. In addition, communication tools such as a transfer summary report, a unit-based/department newsletter and a reporting form to the coordinating council that would not only include the NDNQI data but also the comparative event report data.