A retrospective analysis of the findings of pressure ulcer investigations in an acute trust in the UK

The root cause analysis (RCA) process has been applied in this organisation since 2010 to investigate all severe pressure ulcers. A previous analysis of the findings from all RCAs completed during 2011-2013 identified actions for practice improvement. The current study reports the results of a further retrospective analysis following implementation of new evidence based investigation process.

Aim: To analysis the findings from pressure ulcer investigations; compare the results to the previous study and reflect on the new investigation process.

Methods: Analysis was performed on data from completed RCAs during January-October 2014 to identify key themes and learning points.

Results: Thirty two pressure ulcer RCAs were included. Nutrition was the most common contributory factor, highlighting the issue of malnutrition in an acute care setting. The second most common contributory factor was medical conditions that lead to poor tissue perfusion.

Conclusion: Severe pressure ulcers rarely occur due to a single root cause, but often due to a sequence of events. Patients frequently have multiple complex needs that increase their susceptibility, when this is in combination with a failure of care, a severe pressure ulcer can occur. The new investigation process had limited success in identifying organisational factors. Further work is needed to support staff in the investigation process.