Tracking Pressure Ulcer Incidence and Root Cause Analysis Data with the use of a Shared Drive

Abstract:

This project involved the creation of an electronic Root Cause Analysis form and database through a Shared Drive in a large academic Level One-Trauma Hospital in South East Michigan. The goal of the Shared Drive was to create a way to track pressure ulcer incidence and recognize common themes through a root cause analysis (RCA) done in real time. Tracking our hospital incidence of pressure injuries posed a challenge for data collection. Prior to our creation of the Shared Drive our only way to track pressure injuries was done during scheduled Prevalence Studies submitted quarterly to NDNQI, which provided us information at that day and time only. Recognizing that this was only a snap shot of the number of pressure injuries in our institution and not a true incidence of day-by-day injuries and our inability to obtain any information regarding contributing factors made is necessary for us to improve our tracking system. Although it is early in our data collection to date over 130 patients have been submitted to an electronic Share Drive by department managers, Clinical Nurse Specialists and staff. The Shared Drive has given us the ability to identify common units and locations of injuries and identify opportunities to improve our pressure injury rates improving patient care, quality indicators and reimbursement.