Journey Toward Zero Harm: Reducing Hospital Acquired Pressure Injuries with Apparent and Systemic Cause Analysis

Introduction:  To prevent hospital acquired pressure injury (PI) WOC nursing services partnered with nursing quality. The use of bundled PI prevention efforts^{1, 2, 3} was augmented with apparent cause analysis (ACA) and systemic cause analysis (SCA) for each incidence of PI⁴. For each PI a non-judgmental ACA debriefing was conducted to identify missed opportunities and corrective actions. If trends were noted an SCA was conducted.  

Methods/Process of ACA and SCA:  Identification of PI is reported to and validated by WOC nursing. Nursing quality and nurse managers are notified. Nursing quality reviews the EMR and gathers clinical and documentation data related to patient and PI. A unit based ACA is scheduled; all members of the interprofessional team are invited to attend.  

The ACA begins with a summary of events leading to the PI. Missed opportunities for PI prevention are discussed. Participants discuss barriers, challenges, and deficits that contributed to the PI. A summary and correction action plan is emailed to all staff involved in the patient’s care.

An SCA is conducted when trends are identified. Using a plan-do-study-act framework WOC nursing and quality collaborate with key stake holders/decision makers to develop strategies for improvement. Small tests of change are made to find potential solutions and prevent further patient harm. The scope of the project dictates follow-up meetings and interventions. The workgroup is dismissed after the interventions are deemed successful, and reconvened if the problem recurs.

Results/Data:  HAPI incidence declined from 2.78 to 1.16. Systems issues were identified (lack of wedges, cushions, heel protectors) and rectified.

Conclusions:  Use of ACA and SCA processes has led to decreased PI Incidence, increased engagement of caregivers, and implementation of PI bundle elements. SCA revealed trends that required corrective actions. Non-threatening ACA and SCA led to increased accountability and comprehensive PI preventive interventions across disciplines.