Getting to the Bottom of the Problem: Using the RCA process to identify the etiology of pressure ulcers

Pressure ulcers remain a profound, persistent, resistant problem in most hospitals. The caregivers at our hospital are committed to identifying the risks of pressure ulcer development and had already implemented many processes for early identification of risk, including the use of the Braden Scale for risk assessment, our pressure ulcer prevention protocol, a redistribution waffle chair cushions for all orthopedic patients, and daily skin assessments.

Patients who undergo surgery for hip fracture repair are especially vulnerable to skin breakdown, and when despite all efforts we saw sudden increase of buttock pressures ulcers in this population, we decided to take action.

The root cause analysis (RCA) was utilized to understand the cause for our pressure ulcer increase, striving to eliminate the risk of pressure ulcers in our future hip fracture patients. A team of staff nurses and nurse leaders from departments around the hospital participated in the non-punitive RCA.  Our Wound Care Ostomy Nurse led the team into a deep dive to evaluate the etiology of these pressure ulcers by comparing selected patient’s side-by-side, and the team decided on the new interventions, including fracture hip patients being transferred off stretchers and onto redistribution mattresses/hospital beds in the Emergency Department. In addition, new padding was procured for the OR fracture table; this change was made after a subgroup visited the Operating Room, where the Clinical Nurse Specialist was able to lie on the fracture table to “live the patient experience”. We also have a team currently being procured to evaluate the prospect of new redistribution mattresses for all inpatient beds.

These changes have resulted in zero pressure ulcers in the postoperative hip fracture patients – evidence of the efficacy of the RCA and nurses committed to getting to the bottom of the problem!