Creating a culture of Safety: Decreasing Hospital Acquired Pressure Ulcers

(Abstract: Professional Practice--Implementing a pressure ulcer reduction program) 

Since 2009 the incidence of hospital acquired pressure ulcers at this acute care facility has decreased by 75% with no stage IV ulcers during that time frame and no stage III ulcers for 1.5 years . The change has occurred with great effort by the Wound Ostomy Team in conjunction with Nursing CEP’s, Skin Care Team, staff members, nursing and hospital administration and personnel from all departments.

 Hospital acquired pressure ulcers cause patient’s harm, increase hospital cost and affect the hospital’s reputation in the community.

There has been a concerted effort within this hospital system to attack this problem. Two separate campuses have actively participated in the change process. The incidence of hospital acquired pressure ulcers was very high, above industry standards.  This poster will review problem identification--where was the break in the process? Identify why pressure ulcers occured and what were the barriers? Discuss in detail the processes that took place to change the problem and review the dramatic results.

This multidisciplinary work has taken place at all levels of the organization. This work has resulted in consistent and drastic decrease in hospital acquired ulcers, improved patient, staff and physician satisfaction and has created a culture of safety for skin care within this facility.