Maximising opportunities for learning
Not all pressure ulcers are avoidable. Many patients have co-existing conditions and factors that
increase their risk and despite best care, pressure damage cannot be prevented.
There are however many pressure ulcers that are preventable. The Trust has made significant
progress in pressure ulcer prevention and management over the past few years.
Avoidable Pressure ulcers
Processes have been developed to determine how and why every
hospital acquired pressure incident has occurred. In response, a
Pressure Ulcer Incident review is undertaken for all Stage 3 and above
incidents to identify key themes for learning.
The Trust continues to provide robust mandatory face to face training
for all clinical staff whereby learning from these incidents is shared,
empowering and inspiring staff to provide high quality, safe and effective
care by bringing the learning back
to the workplace.
In addition, all facilities are
encouraged to openly display their
individual standard of pressure ulcer prevention in the form of
a safety cross which indicates the number of days between
the development of pressure ulcers in that facility. These tools
enable each ward to benchmark their own progress and provide
easy access of this information to all staff, patients and the
public.
• Continue to monitor compliance with the 'SSKIN Bundle'
• Continue to monitor and report the number of pressure ulcer incidents, including the
number of severe pressure ulcers (grade 3 & 4) that were considered avoidable
• Work towards sustaining a reduction in the number of severe avoidable facility acquired
pressure ulcers
• Review the Trust Acquired Pressure Ulcer Incident Reporting and Investigation process
• Continue to maximize learning from each incident of severe pressure damage
• Continue to provide mandatory pressure ulcer education and bespoke training in specific
clinical areas as determined through analysis of incident reports and KPI data
• Continue to monitor primary care pressure ulcer prevention strategy & monitor regional
KPI for this patient population
• Continue to recognise ward staff for their achievements in providing pressure ulcer free
care
• Recognise Primary Care for their achievements in providing pressure ulcer free care
• Redesign the community SSKIN bundle.
NEXT STEPS
Goal 3: Measuring the Improvement
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