Patient Safety pp 211-230 | Cite as

Pressure Ulcers

  • Grace M. Blaney
  • Monica Santoro


This chapter explores strategies to prevent pressure ulcers through the lens of two cases involving healthcare-acquired pressure ulcers that are subject to root cause analysis. Emphasis is on a team-based, systematic approach to promote reliable implementation of evidence-based best practices. The case studies demonstrate the multiple factors that contribute to the development of healthcare-acquired pressure ulcers and the complexity of the systems within which they occur; including transitions in care across the continuum, management of critically ill patients, and management of spinal cord injury patients. The prevention of healthcare-acquired pressure ulcers are reviewed in the context of a multifaceted approach addressing organizational policies and processes, assessment, ongoing education and training, patient-centeredness, communication and team work, technological support, and point-of-care resources. The case studies also illustrate the use of root cause analysis to identify latent failures, promote continuous organizational learning, and plan strategies that will result in sustained improvement.


Pressure Ulcer Cervical Collar Root Cause Analysis Skin Integrity Deep Tissue Injury 
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Copyright information

© Springer Science+Business Media, LLC 2014

Authors and Affiliations

  • Grace M. Blaney
    • 1
  • Monica Santoro
    • 2
  1. 1.CWOCN, Wound Care RN, Nursing AdministrationWinthrop University HospitalMineolaUSA
  2. 2.Patient Safety, Quality and InnovationWinthrop University HospitalMineolaUSA

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