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Despite the availability of research based guidelines that describe best practice interventions that should prevent pressure ulcers, patients continue to suffer from these injuries. According to a December 2008 report by the Healthcare Cost and Utilization Project (HCUP) in 2006 there were 503,000 hospital stays with pressure ulcers noted as a diagnosis, representing an almost 80% increase in the incidence of pressure ulcers since 1993. Duncan (2007) reports pressure ulcer–related complications sustained in hospitals result in an estimated 60,000 deaths each year. In response to an increasing focus on patient safety, a partnership between two international organizations was formed and a plan was devised that would permit one nurse specialist to participate in a one year project focused on pressure ulcer prevention. The goal of the project is to decrease hospital acquired pressure ulcer rates and increase staff compliance with pressure ulcer programs and protocols. Four hospital systems agreed to participate in this project which included an inventory of their current pressure ulcer programs, assistance with identifying barriers to bedside implementation and support of their efforts to overcome those barriers. This presentation will detail the journey of the nurse specialist, the process for understanding bedside caregiver challenges, the development of an inventory form that can identify gaps in existing programs and the experiences of each hospital system as they strive to achieve the goal of zero hospital-acquired pressure ulcers. A series of site visits allowed for observation of bedside practices and meetings with clinicians in which specific barriers to implementation were identified. Data collection is ongoing. Various process improvement methodologies, action plans and project results will be presented.