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PSIRF and Pressure ulcer reviews

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Hi All

Pressure ulcers are one the highest reported incidents/ areas for investigation within my directorate and I can see both arguments for investigating to the enth degree or not at all. I sit in the middle, of course! How have the early adopters approached pressure ulcer incidents and investigating these. I know my tissue viability colleagues are slightly twitched by the changes.

I welcome all thoughts and am open to ideas!


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Hi John,

We have experienced this challenge with TV and Falls, managing anxieties is a huge part of the preparation work for PSIRF, we're an early adopter and people are still a little twitchy.

I keep reiterating that we should be driven by the opportunity of new learning, not generating the same findings each investigation which is what we have found happens within TV and falls.

We are using an Incident Risk and Mitigation form for the managers to review the incident and make a recommendation about whether additional review is required, we ask them to take into consideration what we already know and what action/improvement activity is already in place as part of the decision making, this is then reviewed by the subject matter expert as part of the assurance.

I have attached our form in case it helps.

Best wishes


Pressure injury IRMF V3.docx

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