Summary
A hospital-acquired pressure ulcer (HAPU) is a localised lesion or injury to the underlying tissue (wound) that happens while a patient is staying in hospital. It occurs when standardised nursing care is not correctly followed in the presence of friction and shear, leading to skin or underlying tissue breakdown. Unfortunately, inadequate knowledge of nurses to assess and provide standardised care for pressure ulcers or manage HAPUs results in patient harm. This study shared lessons from a reported HAPU incident and aimed to address the knowledge gap in patient safety risk assessment, identification and wound management at Nyaho Medical Centre (Accra, Ghana).
Content
A review of HAPU incidents was conducted using quality improvement tools such as cause-and-effect analyses to identify contributing factors and root causes. Subsequently, plan-do-study-act (PDSA) cycles were used to test interventions to improve pressure ulcer assessments and wound management. A run chart was used to analyse and evaluate the interventions over time. Development of policies, SOPs and training for assessing and managing pressure ulcers and wounds reduced the number of HAPUs during the project period. This project demonstrated that the combined use of quality methods and tools can be suitable for improving processes and outcomes for patients at risk for HAPUs.
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