Hospital-acquired pressure ulcers
In 2013, Texas Children’s Newborn Center had a nearly 70 percent decrease in the overall
hospital-acquired pressure ulcers (HAPU) rate.
The Newborn Center team joined a hospital-wide initiative to improve HAPU rates
by communicating best practices as they were implemented. Interventions focused on
addressing failures of systems rather than individuals and providing the tools necessary to
make it easy for frontline care providers to do what’s right for each patient. The work to
improve HAPU rates follows the tenets of High-Reliability Organization:
Sensitivity to operations:
Increased awareness of leadership and frontline staff to the
importance of prevention and early recognition of HAPU, along with global understanding
of systems in place for patient care that may increase HAPU risk.
Reluctance to simplify:
Occurrences of HAPU warrant “deep dives” into causative
factors; simplistic explanations are not readily accepted. Examination of occurrences
focuses on system failures rather than individual failures.
Preoccupation with failure:
Reporting and examination of near-misses (in this case,
HAPUs caught in the earliest stages of development) helps expose persistent weaknesses
in systems intended to prevent HAPU development. Reporting near misses is encouraged
and recognized as best practice. Nurses receive accolades from leaders for this type of
voluntary reporting.
Deference to expertise:
Frontline care providers have been engaged in every step of
improvement that impacts their daily workflows and work environment. “Don’t plan for
them, without them.”
Resilience:
HAPUs may still occur in some instances despite the efforts of frontline care
providers and leadership in the Newborn Center. The team demonstrates resilience by
continuing to push forward in the face of adversity and celebrates achievements often and
publicly, rather than focusing on failures.
The HAPU improvement initiative involved a collaboration among key caregivers with
each member of the team clearly understanding his or her role in preventing HAPUs.
January 2013 rate
0.82
/1,000 patient days
December 2013 rate
0.25
/1,000 patient days
N U R S I N G O U T C O M E S
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