The Flight to Never-Never Land: Making Skin Failure a Never Event in Critical & Acute Care

Bedside staff nurses hold primary accountability for the protection of patients' skin during hospitalization and need up-to-date knowledge about skin failure.  Guided by a theme of Peter Pan in Never-Never Land, this poster will show how our facility took a journey to change the culture to Neverland. System-wide implementation of five evidenced-based strategies for wound prevention and treatment, including bedside report, root cause analysis, educational materials and roll-out plans, support surface selection, and engaging the "lost boys" of the ER and OR, are illustrated through an exemplar. Two key features of the plan were the introduction of a wound/skin care prevention/treatment protocol and a new process to streamline skin care products.  Content and teaching strategies for the mandatory educational sessions will be shared.  Nurse's roles at all organizational levels will be described and tips will be offered to empower and energize nurses about skin protection.  Led by our WOCN team, the implementation of our education plan over a year created a culture of urgency and passion among nurses for achieving the high standard of never having a pressure ulcer.  We decreased our nosocomial pressure ulcers hospital-wide by 53%, the intensive care unit by 63%, and on our orthopedic unit by 36%, thus consistently outperforming quarterly NDNQI incidence rates.