Pressure Ulcer: Safety Score Improvement Plan | Free Essay Example

Pressure Ulcer: Safety Score Improvement Plan

Words: 939
Topic: Health & Medicine


Each medical facility should make an effort to create and maintain a culture of patient safety and quality care. However, the maintenance process is reliant on the actions of nursing professionals. The presented general hospital allows for more than 1,200 patients to be treated at the same time in its various specialty centers, including a burn center. The number of patients in need of a long-term hospitalized stay is large, and the recent financial crisis made the maintenance of patient safety a much harder process.

The hospital reports all of its performance data to a nongovernmental organization focused on ranking medical facilities based on their scores. The recent scores from the burn center of the hospital have shown a dramatic decrease in patient safety associated with the development of pressure ulcers. The results forced the nurse manager to address the problem due to possible cuts from Medicaid and Medicare programs that low scores may bring.

Factors Contributing to the Decrease of the Patient Safety Score

Pressure ulcers have become an increasingly common patient safety issue in recent years. Some patients are more at risk of developing pressure ulcers than others. They include patients recovering from burns, malnourished patients, and people from various ethnic communities. Pressure ulcers are preventable, but if left untreated they may cause serious harm to the patient.

Systems theory could be used to examine this issue as a nursing challenge. The development of pressure ulcers can be treated as an adverse effect connected to the quality of care provided by nursing professionals. The function of the hospital as a whole is put at risk by this issue. Therefore, the issue should be solved as soon as possible. Experienced nursing leaders are required to fulfill this task.

Influence of Leadership on the Process of Change

Due to the size of the general hospital, it employs a large number of nursing professionals at the clinical and organizational levels. Their duties include strategic planning, staff management, patient care activities, and training supervision. Their primary goal is to streamline patient safety and quality of care. Their role in the change process should not be underestimated because it is connected to almost all of their functions (Wong, Cummings, & Ducharme, 2013). To resolve this issue, they will likely require a focus on patient-centered care in the burn center.

Effect of Current Policies and Procedures on the Safety Issue

Policies and procedures are capable of shaping almost all aspects of hospital operation. They govern management practices, issues related to resources, and types of health care delivery. Since the issue is related to staff management, it is the most important effect of the solution to this issue.

The systems theory can serve as a base for staff management in this case. It states that people put safety and quality at risk by overestimating the abilities of others and downplaying the risks. To address the issue of pressure ulcers a change in staff management policies is required. By implementing a dynamic systems model, nursing leaders will be able to monitor and examine staffing policies. However, before changes may be implemented, research would have to be done to collect the required data.

Recommendations to Ensure Patient Safety

To develop quality recommendations, a data collection process needs to be performed. Data collection will be used to choose the evidence-based strategy. Subsequently, this strategy will be implemented through a safety improvement plan.

Data Collection

The process of data collection will be performed through root cause analysis. Root cause analysis allows the research team to analyze the issue from a more systematic perspective. The goal of such analysis is to find the reasons behind the issue that go outside the idea of individual responsibility. The primary tools of this analysis include cause and effect diagrams and flow charts.

Evidence-Based Strategy

Pressure ulcer prevention methods have been examined from a variety of perspectives. One of the most common ones is focused on the increased attention to the patients who are at risk of developing pressure ulcers. However, the approaches to the attention differ between research teams. Two solutions are effective in real-life hospital settings. The first relies on the need to provide special bedding conditions to the patients at risk and the use of advanced skincare products during their hospitalization (Sullivan & Schoelles, 2013). Due to the present economic crisis, this may prove to be an expensive solution.

The second solution is based on staff management. Some hospitals have created would-care teams that are focused on the prevention of pressure ulcers and other wound-related issues (Tran, McLaughlin, Li, & Phillips, 2016). The implementation of the second solution may prove more appropriate for the current hospital setting.

Implementation of Safety Recommendations and Monitoring of Outcomes

The quality indicators during the implementation of wound-care teams would be based on the number of developed pressure ulcers before and after the program is introduced. They would be monitored through the analysis of quarterly scores by the nursing leaders of the burn center. The procedures would be changed to provide additional attention to patients at risk of pressure ulcer development. Training would be required for the staff assigned to the would-care groups and would be provided inside the facility by the nursing professionals who are most experienced in wound care. The standard staff management tools should be efficient enough for the implementation.


Pressure ulcers have a major effect on patient safety. Nursing leaders have to address the issue through the use of systems theory to avoid losing funds from Medicaid and Medicare programs. By implementing wound-care teams, pressure ulcers can be prevented, and the safety standards of the hospital may be maintained.


Sullivan, N., & Schoelles, K. (2013). Preventing in-facility pressure ulcers as a patient safety strategy. Annals of Internal Medicine, 158(5), 410.

Tran, J., McLaughlin, J., Li, R., & Phillips, L. (2016). Prevention of pressure ulcers in the acute care setting. Plastic and Reconstructive Surgery, 138, 232-240.

Wong, C., Cummings, G., & Ducharme, L. (2013). The relationship between nursing leadership and patient outcomes: A systematic review update. Journal of Nursing Management, 21(5), 709-724.