Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries

Many hospital settings are adopting a zero-tolerance policy towards pressure injury (PI) development; this requires good planning and the implementation of care, as the incidence of PIs reflects the quality of care given in a hospital or facility.

To identify common contributing factors towards the development of PIs in a geriatric rehabilitation hospital and improve patient safety through the reduction of hospital-acquired PIs.

This was done using root cause analysis (RCA). All patients who developed a Stage 3 or 4 deep tissue injuries or unstageable hospital-acquired PI between December 2017 and April 2018 PIs were investigated using RCA. The RCA was facilitated through the use of a contributing framework developed by the National Pressure Ulcer Advisory Panel which guides investigations of different areas of care. Qualitative and quantitative data was collected from several sources and placed in a timeline to reconstruct the series of events. The investigator then identified if the PI was avoidable or not by comparing the evidence with pre-set criteria. Content analysis was further used to analyse the themes retrieved.

A variety of root causes were common amongst all the cases. These included both flaws in the system, such as poor equipment and inadequate educational programmes, as well as human factors such as a lack of basic routine care. No skin assessment was being performed (n = 0) apart from the assessment done on admission. Documentation of action planning when it comes to PI prevention was also missing (n = 0). It was identified that 7 patients were mobilized on admission while the others (n = 3) had a delay in mobilisation, due to some fragmentation in care. There was no documentation of patient and relative education on the prevention of PIs (n = 0). All the patients were provided with the right pressure redistributing mattress however, some mattresses were bottoming out. Some causes overlapped, with system defects like lack of protocols, equipment and tools pushing human errors to occur. This created a series of events leading to the adverse event. The identification of these factors helped to provide an understanding of the changes that are needed to reduce future harm and improve patient safety.

Recommendations were proposed to reduce contributing factors to the development of hospital-acquired PIs. These include audits to reinforce adherence to hospital guidelines, streamlining of the documentation system, investment in new equipment and improvements to educational programmes. The recommendations implemented resulted in a decreased incidence rate of HAPIs.