Forkuo-Minka AO, Kumah A, Asomaning AY, et al.
Global journal on quality and safety in healthcare. Date of publication 2024 Feb 12;volume 7(1):15-21.
1. Glob J Qual Saf Healthc. 2024 Feb 12;7(1):15-21. doi: 10.36401/JQSH-23-25.
eCollection 2024 Feb.
Improving Patient Safety: Learning from Reported Hospital-Acquired Pressure
Ulcers.
Forkuo-Minka AO(1), Kumah A(2), Asomaning AY(2).
Author information:
(1)Directorate of Nursing, Nyaho Medical Centre, Accra, Ghana.
(2)Directorate of Quality, Nyaho Medical Centre, Accra, Ghana.
INTRODUCTION: A hospital-acquired pressure ulcer (HAPU) is a localized lesion or
injury to the underlying tissue (wound) while the patient is on admission. It
occurs when standardized 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 standardized
care for pressure ulcers or manage HAPUs results in patient harm. We aim to
share lessons from a reported HAPU incident and address the knowledge gap in
patient safety risk assessment, identification, and wound management at Nyaho
Medical Centre (Accra, Ghana).
METHODS: 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 analyze and evaluate the interventions over 12 weeks (Aug-Oct
2021).
RESULTS: Development of policies and a standard operating procedure for pressure
ulcers and wounds improved accuracy in identifying pressure ulcer risks and
management of wounds. Eighty-three patients were assessed with the pressure
ulcer assessment tool. Complete (100%) adherence to the pressure ulcer and wound
policy and standard operating procedure (SOP) was achieved, and the number of
HAPUs decreased from five to one during the study period.
CONCLUSION: This study demonstrated that the combined use of quality methods and
tools can be suitable for improving processes and outcomes for patients at risk
for HAPUs.
DOI: 10.36401/JQSH-23-25
PMCID: PMC10887484
PMID: 38406657
Conflict of interest statement: Source of Support: None. Conflict of Interest:
None.
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