The incidence of pressure ulcer injuries in Pediatric Intensive Care Units (PICU) has been reported to be as high as 43%. Despite limited research in prevention and treatment of Hospital Acquired Pressure Ulcers (HAPU) in pediatrics, a true skin bundle has yet to be developed for the pediatric patient. Most of the injuries sustained in PICUs across the country have been determined to be preventable. National efforts have been made to eliminate such harm and have become regulatory standards as well as Nurse Sensitive-Outcomes. The PICU at NCH has developed a multifaceted quality initiative approach to determine the incidence of pressure ulcer injury, implement prevention interventions, identification of risk factors, and focuses on detection. Prevention strategies such as the creation of a prevention bundle and monthly audits to ensure compliance was first established. Additionally, a standardized turning schedule, implementation of positioning devices, rotation schedule for all medical devices and the importance of teamwork helped to achieve sustained success. From 2010 to November 2013, NCH PICU has decreased the injury count and the severity of injuries being detected in the Pediatric Intensive Care Unit. As of November 1, 2013 the PICU has reduced the number of pressure ulcers detected by 50% from 2012. The development of a dedicated unit based skin team was vital to this project success. The unit based team focused their efforts on defining and improving clinical practice resulting in development of a pressure ulcer prevention bundle based on the data discovered during weekly detection rounds. HAPUs are associated increased morbidity and mortality in critically ill pediatric patients. The success of this quality initiative is evidenced by change in clinical practice resulting in decreased harm to the patients.