Patient Safety Topics
:
Pressure Injuries
Overview

​Pressure injuries are a recognized patient safety concern and meet the definition of a reportable event under the Pennsylvania Medical Care Availability and Reduction of Error (MCARE) Act.

In a previous Pennsylvania Patient Safety Advisory article, Authority analysts discussed the increasing frequency and severity of pressure injury events that were reported in Pennsylvania. The article highlighted opportunities to improve pressure injury recognition, and patient awareness. Further, the Authority sought to standardize reporting of these injuries.

In Pennsylvania, acute healthcare facilities report pressure injuries through the Authority's Pennsylvania Patient Safety Reporting System. In January 2018, new guidelines for reporting went into effect.

Key Data and Statistics
​Figure. Pressure Ulcer Events Reported to the Pennsylvania Patient Safety Authority, by Level of Harm, 2007 through 2013

​Figure. Pressure Ulcer Events Reported to the Pennsylvania Patient Safety Authority, by Level of Harm, 2007 through 2013

 

Pennsylvania hospitals reported more than 19,000 pressure ulcer events to the Pennsylvania Patient Safety Authority in 2013. Analysis of the actual events made evident the increasing frequency and severity of pressure injury events that were reported in Pennsylvania from 2007 through 2013. 

Excerpted from: Feil M, Bisbee J. Hospital-acquired pressure ulcers remain a top concern for hospitals. Pa Pat Saf Advis 2015 Mar [cited 2017 Oct 1]. http://patientsafety.pa.gov/ADVISORIES/Pages/201503_28.aspx 

Educational Tools

​Online Education for Reporting of Pressure Injuries
This program memo describes how acute reporting facilities in Pennsylvania can participate in online education about pressure injuries through the Pennsylvania Patient Safety Authority. Three modules provide specific information about the final guidance and changes to Pennsylvania Patient Safety Reporting System (PA-PSRS), intended for patient safety officers (PSOs), risk managers, nurses, and other clinical and non-clinical workers responsible for reporting through PA-PSRS. A fourth module provides evidence-based recommendations about how to prevent pressure injuries from occurring, intended for physicians, advanced nurse practitioners, physician assistants, registered nurses, PSOs, and individuals responsible for reporting into PA-PSRS.

Decision Tree for Reporting Pressure Injuries
This decision tree is provided to support decision making for reporting pressure injuries that meet the statutory definitions of Incidents or Serious Events as defined under the Medical Care Availability and Reduction of Care (MCARE) Act.

 

 

 

Multimedia
Overcoming Challenges in Pressure Injury Reporting: Two Facility Perspectives
 
 

Hospital-Acquired Pressure Ulcers Remain a Top Patient Safety Concern
 
 
Safety Tips for Patients

 

©2018 Pennsylvania Patient Safety Authority