Preventing Pressure Ulcers
Patients in the hospital are at risk of developing pressure ulcers, or bedsores, if their skin is exposed to unrelieved pressure. Pressure ulcers are typically the most reported adverse health event. According to the Agency for Healthcare Research and Quality, each year more than 2.5 million people in the U.S. develop pressure ulcers. The injuries to the skin and underlying tissue are painful and increase risk for infection or other complications.
In addition to patients who cannot change position, the following circumstances increase the risk of a patient developing a pressure ulcer:
- Wetness from continuous or periodic loss of bowel
- Not eating or drinking enough
- Reduced mental awareness or confusion and/or bladder control
- Medical devices against the skin
Minnesota hospitals are hard at work to eliminate serious pressure ulcers for patients and great progress has been made. Since 2003, hospitals have been reporting stage III and stage IV pressure ulcers to the state. Beginning in 2007, hospitals also started reporting unstageable pressure ulcers to the state.
In 2007, the Minnesota Hospital Association initiated the Call to Action framework around skin safety, resulting in SAFE SKIN. SAFE SKIN provides hospitals with resources of best clinical practices to prevent pressure ulcers, a road map of best practices and a tool kit to implement the road map recommendations in their facilities. The SAFE SKIN road map is based on the Institute for Clinical Systems Improvement (ICSI) Skin Safety Protocol; Wound, Ostomy and Continence Nurses Society's (WOCN) Clinical Practice Guidelines; International Pressure Ulcer Guidelines; and goes a step further to incorporate learnings from Minnesota Adverse Health Events (AHE) reports since 2006.
Based on AHE findings, MHA launched SAFE SKIN 2.0 in 2011 and SAFE SKIN 3.0 in 2015, which makes best practice recommendations for the operating room, prevention of medical device-related pressure ulcers and patients in critical care.
Download the Pressure Ulcer/Pressure Injury road map.