Tissue Viability
Guidance for Reporting and Safeguarding
Version 6.1 FINAL 16th June 2011
June 2011
Page | 1
Acknowledgements
West Midlands Strategic Health Authority wishes to thank the following organisations/groups for
their assistance in compiling this guidance:









NHS Staffordshire
NHS Stoke on Trent
West Midlands Regional Tissue Viability Advisory Group (TAGS)
Heart of Birmingham NHS FT Tissue Viability Team
Bradford PCT
Solihull Care Trust
Staffordshire and Stoke-on-Trent Adult Safeguarding Partnership
University Hospital Coventry and Warwick Tissue Viability Team
West Midlands Regional ‘Your Skin Matters’ High Impact Action Working Group
Further information
For further information please contact:
Contact:
Manjeet Garcha. Interim Head of Patient Safety, NHS West Midlands
Michelle Mello. Modernising Nursing Careers Lead, NHS West Midlands
Telephone: 0121 695 2561/0121 695 2300
Email:
manjeetk.garcha@westmidlands.nhs.uk
michelle.mello@westmidlands.nhs.uk
Page | 2
Contents
1.0 Introduction
- Purpose
2.0 Background
Page
Number
4
4
3.0 Definitions of a Pressure Ulcer
5-7
Definitions of Avoidable and Unavoidable Pressure Ulcers
4.0 Reporting Guidance
- Pressure Ulcer Reporting Chart
- Definition of timescales for Hospital and Primary Care Acquired Pressure Ulcers
- Assurance
5.0 Pressure Ulcer Reporting Flowchart
6.0 Safeguarding
7
8-9
10
11-14
-Pressure Ulcer Safeguarding Triggers Pathway 1
15
-Pressure Ulcer Safeguarding Triggers Pathway 2
16
-Safeguarding Referral Pathway for Pressure Ulcers
17
7.0 References
Appendix
1
Page | 3
18
Appendices
Page
Number
NHS West Midlands High Impact Action
Your Skin Matters Recommended Route Cause Analysis (RCA)
Investigation Report (Template)
19-34
Serious Incident Reporting
Introduction
Experience of reporting and managing pressure ulcer related serious incidents (SI’s) has
indicated the need for additional guidance, support and clarification of the criteria to be used when
evaluating pressure ulcer related serious incidents. This guidance has been designed to offer
further guidance for safeguarding, reporting and investigating tissue viability related pressure
ulcers and should be used in conjunction with the previously published National Framework for
Reporting Serious Incidents (2010) and NHS West Midlands Serious Incident Reporting Policy
(2010).
1.0
Purpose
The purpose of this guidance is to:
a) Ensure management of SI’s related to pressure ulcers conform to the processes and
procedures set out for managing all SI’s
b) There is a consistent approach to evaluating Pressure Ulcers related SI’s
c) Early reports of pressure ulcer reporting SI’s are sufficient to decide on appropriate
escalation, notification and communication to interested parties including Safeguarding
d) Appropriate action is taken to prevent damage to patients, staff and the reputation of the
NHS
e) All aspects of the SI are fully explored and ‘lessons learned’ are identified and
communicated; and
f) Appropriate corrective action is taken to prevent/reduce the number of incidents occurring.
2.0
Background
In November 2009 Dame Christine Beasley, Chief Nursing Officer for England,
launched
the High Impact Action for Nursing and Midwifery’. This document identified 8 key examples of
high quality and cost effective care that potentially would make a transformational difference in the
NHS.
The reduction target for reducing pressure ulcers is now a major work stream in Safety Express,
CQUINs including CNO’s High Impact Actions. The target reduction was set at 80% for hospital
acquired pressure ulcers and 30% for community acquired by 2014 as identified in the Nurse
Sensitive Outcome Indicators (2010).
Pressure ulcers of grade 3 and 4 are to be reported as a serious incident on the Strategic
Executive Information System (STEIS) and to clarify the process; the following reporting guidance
has been developed.
Page | 4
3.0
3.1 Definition of a Pressure Ulcer
A localized area of damaged tissue as a result of pressure in combination with other variables
of which there are 4 grades; these are described in detail on pages 5 and 6.
Grade 1: Non-blanchable erythema
Description: Intact skin with non-blanchable redness of a localized area usually over a bony
prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from
the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to
adjacent tissue. Grade 1 may be difficult to detect in individuals with dark skin tones.
Progression of pressure ulcer
Grade 1
 Non-blanchable erythema (redness) of intact skin.
 Discolouration of skin, warmth, oedema, induration or hardness may also be used as
indicators, particularly on individuals with darker skin
Grade 2: Partial thickness
Description: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink
wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising
(indicating deep tissue injury). This grade should not be used to describe skin tears, tape burns,
incontinence associated dermatitis, maceration or excoriation.
Page | 5
Progression of pressure ulcer
Grade 2
 Partial thickness skin loss involving epidermis, dermis or both
 The ulcer is superficial and presents clinically as an abrasion or blister
Grade 3: Full thickness skin loss
Description: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or
muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.
May include undermining and tunneling. The depth of a grade 3 pressure ulcer varies by
anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose)
subcutaneous tissue and grade 3 ulcers can be shallow. In contrast, areas of significant
adiposity can develop extremely deep grade 3 pressure ulcers. Bone or tendon is not visible or
directly palpable.
Progression of pressure ulcer
Grade 3
 Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may
extend down to, but not through the underlying fascia.
Grade 4: Full thickness tissue loss
Description: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar
may be present. Often includes undermining and tunneling. The depth of a grade 4 pressure
ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not
have (adipose) subcutaneous tissue and these ulcers can be shallow. Grade 4 ulcers can
extend into muscle and/or supporting structures (e.g. fascia, tendon or joint capsule) making
Page | 6
Osteomyelitis or osteoitis likely to occur. Exposed bone/muscle is visible or directly palpable
EPUAP (2009).
Progression of pressure ulcer
Grade 4
 Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures
with or without
full thickness
skin loss. pressure ulcers
3.2 Defining
avoidable
and unavoidable
In the absence of definitions in the UK, the Department of Health has used two definitions from
The Wound, Ostomy and Continence Nurses Society of the US and created one modified
definition for use in the UK:
Avoidable Pressure Ulcer: “Avoidable means that the person receiving care developed
a pressure ulcer and the provider of care did not do one of the following; evaluate the person’s
clinical condition and pressure ulcer risk factors; plan and implement interventions that are
consistent with the persons need and goals, and recognised standards of practice; monitor and
evaluate the impact of the interventions; or revise the interventions as appropriate.”
Unavoidable Pressure Ulcer: “Unavoidable” means that the person receiving care developed a
pressure ulcer even though the provider of the care had evaluated the person’s clinical condition
and pressure ulcer risk factors; planned and implemented interventions that are consistent with the
persons needs and goals; and recognised standards of practice; monitored and evaluated the
impact of the interventions; and revised the approaches as appropriate; or the individual person
refused to adhere to prevention strategies in spite of education of the consequences of nonadherence”.
Guidance: In determining whether the pressure ulcer is avoidable; commissioners, regulators or
others could request to see evidence demonstrating the actions outlined in the “avoidable”
definition are demonstrated.
Page | 7
4.0
Reporting Guidance
The guidance chart for reporting pressure ulcers can be found in figure 1 and a flowchart
capturing the timescales for reporting and investigating can be found in figure 2
Figure 1
STAGE
Reporting
organisation
Pressure Ulcer Serious Incident Reporting Chart
ACTION
 Hospital acquired grade 3 and 4 pressure ulcers should be reported
on STEIS by the acute Trust.
 Primary care acquired pressure ulcers should be reported on STEIS
by the community provider organisation and performance managed
by commissioners via the Care Quality Review process.
 Primary care acquired pressure ulcers in commissioned independent
providers should be reported on STEIS by the commissioning
organisation, this includes care commissioned in nursing or
residential care homes.
 Incident found in patients own homes where there is no input from
any health services, these should be reported to the commissioner
and internal analysis undertaken of any significant trends. These do
not need to be reported on STEIS.
Safeguarding
 All Grade 3&4 Pressure Ulcer Incidents should first be assessed for
evidence of neglect or abuse and if this is substantiated then reported
to the trust safeguarding lead for further investigation. (The person
(s) undertaking the initial assessment must have undertake
appropriate Safeguarding training).
 Should signs of neglect be identified using locally agreed or regional
tissue viability criteria, the Trust must report this to the Local
Safeguarding Board and the Care Quality Commission (CQC).
Reporting
Timeframe
Root Cause
Analysis
Page | 8
 All incidents should be reported on STEIS within 2 working days in
line with the SHA’s policy for the ‘Reporting & Management of
Serious Incidents’ 2010.
 The Root Cause Analysis (RCA) should be completed within
21 working days following notification of the incident. This is in line
with current local agreed CQUINs and the SHA High Impact Action
Group for ‘Your Skin Matters’.
STEIS Closure
 On completion of the RCA, the lessons learnt and actions planned
and completed must all be summarised on STEIS; the Trust can then
request closure from the SHA, including any actions arising from
referral to the Local Safeguarding Adults Board.
 The commissioning PCT should also assure compliance with action
plans via the normal Quality Review Group Meetings.
Page | 9
4.1
Definition of timescales for Hospital and Primary Care Acquired Pressure Ulcers
For patients admitted or transferred to a healthcare setting without any obvious signs or symptoms
of skin damage, the development of a stage 3 or 4 pressure ulcer within 72 hours of admission
to that institution is likely to be related to pre-existing damage incurred prior to admission or
transfer of care.
For any pressure area damage arising after 72 hours thereafter, the most likely cause will be
related to care within the healthcare setting the patient is in, this must be regarded as a new event.
All professionals must ensure that pressure ulcer details are stated in any clinical correspondence
e.g. discharge or admission letter, should clearly identify relevant information in respect to the
initial source of occurrence
4.2
Assurance
It is the responsibility of the Commissioner to ensure that all grade 3 and 4 pressure ulcers are
reported on STEIS and investigated. In addition, the trust must ensure that the incidence and
progress is analysed and reported internally through the organisation’s governance reporting
framework and ultimately to the Trust Board.
Page | 10
5.0
Pressure Ulcer Reporting Flowchart
Figure 2: Flow Chart showing timescales for reporting and investigating
Incident
Pre 72 hrs
Community
Post 72 hrs
Hospital
Report on STEIS and refer to trust Safe Guarding Lead within 2 working days
(Assess for suspected neglect)
Yes
No
Report to Local Safe Guarding
Board
And CQC
Investigate and complete RCA with 21 working days
Page | 11
6.0
Safeguarding
6.1
Introduction
This guidance has been written to provide a framework for decision making in relation to
establishing the need for raising a safeguarding referral in the event of tissue damage
occurring.
6.2
What is safeguarding?
Safeguarding is defined within the Staffordshire and Stoke on Trent Inter-agency adult
protection procedures (2010) as “All work which enables an adult who is or may be eligible for
community care services to retain independence, wellbeing and choice and to access their
human right to live a life that is free from abuse and neglect” This includes people in need of
health care services.
6.3
Who is a vulnerable adult?
Vulnerable adult is a term used to describe a person who is aged 18 or over, who is, or may be
in need of community care services, by reason of mental or other disability, age or illness and
who is, or may be unable to take care of him or herself or take steps to protect him or herself
from significant harm or exploitation. (DOH, 2000)
6.4
What is Neglect or Acts of Omission?
The withholding, either deliberately or unintentionally, of help or support necessary to carry out
daily living tasks. This includes ignoring medical and physical care needs or failing to provide
access to health, social or educational support, the withholding of medication, nutrition and
heating.
Pressure ulcers are cited twice in Staffordshire and Stoke-on-Trent Policy Inter Agency Adult
Protection Procedures (2010);
1. Physical abuse: section 6
Under possible indicators of physical Abuse:
“Ulcers, pressure sores and left in wet clothing”
2. Neglect and acts of omission: section 6
Under possible indicators of neglect
“Inadequate physical care both of the person and the environment”
Page | 12
6.5
What is a pressure ulcer?
A localized area of damaged tissue as a result of pressure in combination with other variables
of which there are 4 grades as described in section 2.1.
Notification Required
6.6
Primary/Secondary Care
A clinical incident form should be completed for all grade 2, 3 and 4 pressure ulcers in line with
the National Institute for Health and Clinical Excellence (NICE, 2005) and all grade 3 & 4
pressure ulcers must be reported as an SI as per the SHA SI Reporting Policy 2010.
6.7
The Health & Social Care Act
Outcome 20 (Notification of other incidents) in the CQC Guidance about Compliance - Essential
Standards of Quality and Safety states:
The registered person (this now includes NHS, Adult Social Care & Independent Health)
must notify CQC of:
"The development after admission of a pressure sore of grade 3 or above that develops after the
person has started to use the service (European Pressure Ulcer Advisory Panel Grading)."
Outcome 20 relates to Regulation 18 of the Care Quality Commission (registration)
Regulations 2009
6.8
Safeguarding adult referral in relation to Tissue viability
Potential indicators for a safeguarding referral:








Development of a Grade 3/4 EPUAP pressure ulcer
Rapid onset/deterioration of tissue damage
Unexplained weight loss/dehydration
Unexplained bruising or injuries of any sort
Poor physical condition i.e. failure to attend to physical needs such as toileting, dressing
and washing
Poor continence management
Burns
Leaving a resident unattended for an extended length of time
This is not an exhaustive list and there may be other areas of tissue viability that would trigger a
safeguarding referral. (See local Safeguarding Adults Policy).
Page | 13
6.9
Reasonable measures that should be taken to prevent tissue damage:













Implementation of, or increase in repositioning regime with clear documentation
Evidence of a 24 hour approach to repositioning at regular intervals appropriate to each
individual
Regular skin inspection and clear documentation to include continence management
and protection of skin with barrier creams and/or emollients
Appropriate plan of care which is updated accordingly and addresses the cause of the
pressure damage.
Care Homes: Monthly risk assessment acknowledging changes in need
Primary care: Three monthly risk assessment or as clinical condition changes
acknowledging changes in need
Secondary care: Risk assessment within 6 hours of admission and daily risk assessment
thereafter
Appropriate equipment with supporting documentation
Nutritional assessment and involvement of necessary professionals
Wound assessment and evaluation to include photographs and regular wound
measurements
Appropriate dressing selection with a treatment chart
Pain assessment and liaison with the GP
Documented evidence of offering care to non concordant residents
Absence of any of the above may indicate a safeguarding referral but would be considered on
an individual basis.
6.10
Factors that may influence the safeguarding referral decision
In some cases pressure ulcer development may be inevitable for example;







Palliative diagnosis
End of life care
Non concordance of patient with recommended treatment and interventions
Multiple co-morbidities
Change in condition
History of development
Capacity and mental health issues( these are patients that may not co-operate with
treatment or prevention interventions due to capacity or mental health problems i.e.
taking off wound care dressings or declining to be repositioned)
This is not an exhaustive list, medical conditions along with other professionals opinions needs
to be taken into account. Reasonable measures still need to be carried out regardless of
diagnosis. Failure to do so may still result in a safeguarding referral
Page | 14
6.11
Consideration of Capacity
If a person lacks capacity to make a decision in relation to the care or treatment of the pressure
ulcer a decision must be taken to act in the best interests of the patient utilizing the Mental
Capacity Act 2005.
The two diagrams (pages 13 and page 14) indicate the pathway for individuals who are
receiving professional support i.e. in a care home, hospital, from a domiciliary care provider, a
nursing agency and those individuals who are not receiving any professional care and are
looked after by an unpaid carer, family or friend.
Page | 15
Pressure Ulcers – Safeguarding Triggers- Pathway 1
To determine if the identification of a pressure ulcer on an individual receiving
professional support (in a care home, hospital or from domiciliary care of nursing agency
care) should result in a safeguarding referral the following triggers should be considered.
IF IN DOUBT
senior manager
Initiate Safeguarding Adults Procedures
Discuss with
Record decision and reasons for decision.
Possibly NOT
Safeguarding
at this stage
Possibly
Safeguarding
Definitely
Safeguarding
1. What is the severity
(grade) of the pressure
ulcer?
Grade 2 pressure ulcer or
below – care plan required
Several grade 2 pressure
ulcers/ grade 3 to 4 pressure
ulcers- consider question 2
Grade 4 and other issues
of significant concern
2. Does the individual
have mental capacity
and have they been
compliant
with
treatment?
Has capacity and declined
treatment
Does not have capacity or
capacity has not been
assessedcontinue
to
question 3
Assessed as NOT having
capacity and treatment
NOT provided
Has
a
assessment
completed?
Capacity assessment
recorded.
capacity
been
is
3. Full assessment
completed and care
plan developed in a
timely manner and
care
plan
implemented?
Documentation
and
equipment available to
demonstrate
full
assessment
completed,
care plan developed and
implemented.
Documentation
and
equipment
NOT
fully
available to demonstrate full
assessment completed, care
plan developed or care plan
implemented BUT general
care regime (e.g. nutrition,
hydration) not of concerncontinue to question 4
Little or no documentation
available to demonstrate
a full assessment has
been completed, or care
plan implemented AND
general
care
regime
(e.g. nutrition, hydration)
is of concern.
4. This incident is part
of a trend or patternthere have been other
similar incidents with
this
individual
or
others.
Evidence suggests this is
an isolated incident.
There have been
similar incidents
Evidence
demonstrates
this is a pattern or trend.
NOT SAFEGUARDING
If 2 or more of the above
apply - SAFEGUARDING
other
SAFEGUARDING
Always clearly record decision and reasons for decision.
Page | 16
Pressure Ulcers – Safeguarding Triggers- Pathway 2
To determine if the identification of a pressure ulcer on an individual with No professional
support (i.e. the only support available is from an unpaid carer/ family member) should
result in a safeguarding referral the following steps should be considered.
IF IN DOUBT
senior manger
Initiate Safeguarding Adults Procedures
Discuss with
Record decision and reasons for decision.
Possibly NOT
Safeguarding
at this stage
Possibly
Safeguarding
Definitely
Safeguarding
1. What is the severity
(grade) of the pressure
ulcer?
Grade 2 pressure ulcer or
below – care plan
required
Several grade 2 pressure
ulcers/ grade 3 to 4
pressure ulcers- consider
question 2
Grade 4 and other issues of
significant concern
3. Does the individual
have mental capacity
and have they been
compliant
with
treatment?
Has
capacity
declined treatment
Does not have capacity or
capacity has not been
assessedcontinue
to
question 3
Assessed as NOT having
capacity and treatment NOT
provided
Has
a
assessment
completed?
capacity
been
Capacity assessment is
recorded.
3. Unpaid carer raised
concerns and sought
support
at
an
appropriate time.
Evidence available to
show concerns raised
and support sought – e.g.
from GP, DN, SW.
Evidence NOT CLEAR that
concerns were raised or
support sought in a timely
manner.
No support sought
4. Full assessment
completed and care
plan developed in a
timely manner and
care
plan
implemented?
Evidence available to
show
unpaid
carer
cooperated
with
assessment and has
implemented care plan
Evidence
of
partial
cooperation
or
implementation of care
plan- some aspects may
have been declined e.g.
certain equipment.
NO cooperation and refusal
to implement care plan and
or purposeful neglect.
5. This incident is part
of a trend or pattern –
there have been other
similar incidents or
other areas of concern
Evidence suggests that
this is an isolated incident
There have been other
similar incidents or other
areas of concern
Evidence demonstrates that
this is a pattern or tend.
NOT SAFEGUARDING
If 2 or more of the above
apply Safeguarding
SAFEGUARDING
and
Always clearly record decision and reasons for decision.
Page | 17
Safeguarding Referral Pathway for Pressure Ulcers
Pressure ulcer: Primary or Secondary Care acquired
Grade 1 or grade 2
EPUAP pressure ulcers
Grade 3 or Grade 4 EPUAP
pressure ulcers
Refer to Tissue Viability Service
Have reasonable steps been made to
prevent/manage pressure ulceration?
Have reasonable steps been made to
prevent/manage pressure ulceration?
See definitions
See definitions
Yes
No
Care Homes with
nursing: Refer to the
Tissue Viability
Service if there are
management
concerns.
Refer to Tissue
Viability/ District
Nurse to address
quality issues with
training and
management advice.
Complete Incident
Form for Grade 2
pressure ulcers
Consideration may be
given to a
safeguarding referral.
Complete Incident
Form for Grade 2
pressure ulcers
Yes
Refer to the Tissue
Viability Service
and/or Intermediate
care /District Nurse
for management.
Complete Incident
Form to Risk
Management.
Complete RCA.
No
Multi Agency
Safeguarding referral
for further
investigation.
Refer to the Tissue
Viability Service
and/or intermediate
Care/ District Nursing
for management.
Complete Incident
Form to Risk
Management.
Complete RCA.
Multi Agency Document for Safeguarding
vulnerable adults and Incident Form to be
completed
Any tissue damage, including bruising or injury needs to be considered on an individual basis.
A referral should be made when deemed appropriate following the local Safeguarding Adults Multi
Agency Guidelines. For advice contact the Safeguarding Adult lead for your area.
Page | 18
7.0
References
Department of Health, (2000) No Secrets
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_
4008486
European Pressure Ulcer Advisory Panel (EPUAP), 2009. pressure ulcer prevention: A quick
reference guide
http://www.epuap.org/guidelines/Final_Quick_Prevention.pdf
Health & Social Care Act, (2008), Department of Health
http://www.dh.gov.uk/en/Publicationsandstatistics/Legislation/Actsandbills/HealthandSocialCareBill/in
dex.htm
High Impact Actions for Nursing and Midwifery. NHS Institute of Innovation and Improvement. 2010
http://www.institute.nhs.uk/building_capability/hia_supporting_info/staying_safe_preventing_falls.html
Inter-Agency Adult Protection procedures Staffordshire and Stoke-on-Trent Safeguarding adults
Partnership (2010) (Web link to follow)
Mental Capacity Act Policy (2009)
http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/LocalAuthorityCirculars/DH_09
6868
National institute for Health and Clinical Excellence (NICE). The Prevention and Treatment of
Pressure Ulcers. (2005) available from http://www.nice.org.uk/
NPSA, “National Framework for Reporting and Learning from Serious Incidents Requiring Investigation”,
2010
http://www.nrls.npsa.nhs.uk/report-a-patient-safety-incident/patient-safety-direct/serious-incidentreporting-and-learning-framework-sirl/
Nurse Sensitive Outcome Indicators DH 2010
http://www.dh.gov.uk/en/Aboutus/Chiefprofessionalofficers/Chiefnursingofficer/Energiseforexcellence
/DH_120765 Reproduced with kind permission from Rebecca Martin- Heart of Birmingham PCT and
Solihull Primary Care Foundation Trust.
Serious Incidents Reporting Policy and Procedure. NHS West Midlands July 2010
Position Paper: Avoidable and Unavoidable Pressure Ulcers. Wound, Ostomy and Continence Nurses
Society (WOCNS) March 2009. Accessed 24/08/2010 http://www.cawc.net/images/uploads/wcc/7-2stevenson.pdf
Page | 19
Appendix 1
NHS West Midlands
High Impact Action – Your Skin Matters
Recommended Route Cause Analysis (RCA)
Investigation Report Template
Learning through Action
To Reduce Primary Care Acquired
Grade 3 and 4 Pressure Ulcers
(This document is based on the National Patient Safety Agency “Learning through action to
reduce infection" and adapted from the West Midlands Regional Tissue Viability Group)
20
Root Cause Analysis (RCA) Investigation Report
Learning through action to reduce the number of Primary and
Secondary care acquired Grade 3 and 4 Pressure Ulcers
Root Cause Analysis Summary
Patient name
Hospital number/ NHS Number
Date of birth
Ethnic Origin
TVN name and designation
Date ulcer verified by TVN
Grade and location
Root causes identified from a
Pressure
analysis of contributory factors:
Friction
Shear
Moisture
Other
Where was the ulcer acquired?
Name of Acute Hospital
Pts own home
Nursing home
Residential home
Community Hospital
Outcome Avoidable/Non
Avoidable/unable to determine
21
What controls or barriers could be used
to prevent the incident from happening
again?
Examples of good practice:
Lessons learned:
Recommendations for change /
identified solutions:
Clinical areas involved
Date of Start of process
Date of completion of RCA process
Signature
Using the above information: Has the pressure ulcer developed whilst under the care of
(your organisation) Yes/ No. If yes, continue to complete full RCA documentation. If no,
report findings to governance. (Datix report etc)
22
Patient Name
Hospital/NHS Number
Patient History (Timeline)
Current admission date to
…………………………………………….
Current ward/Nursing team
Grade and location of pressure
ulcer
Grade:
Previous history of pressure
ulcers?
Yes
Location:
No
Grade and location
Other clinical areas involved in
admission/ Care
Current Diagnosis
Relevant medical conditions
Status on admission
What treatment is the patient
receiving?
Is the patient on the Care of the
Dying Pathway?
Date:
23
Previous Care episodes
Yes/No /not known
Details and Dates
1. Care in nursing /
residential home
2. Own home – primary care
e.g. District nurse, GP ,
podiatry
3. Community and social
care ( home care, day
care)
Transfers
Has the patient been Transferred between care Settings within the last 12 Months
1. Between wards in a hospital
2. Between Hospitals
3. Between care homes
4. Other
Yes/ No
If Yes : Dates and Details:
Summary of care/status immediately prior to pressure ulcer development
Date pressure ulcer found:
Grade:
Immediate action taken by ward / community staff
24
Did the pressure ulcer
deteriorate/improve
Was the patient referred to tissue
viability?
Grade
Dates
Date referred
Date seen
Tissue viability recommendations
Summary of care/status
immediately after pressure ulcer
development
25
Assessment
Was skin assessment completed
within 6 hrs of admission or on
admission to caseload?
If no state when
Condition:
Was patient risk assessed within 6
hrs of admission or on admission
to caseload?
If no state when
Score:
Was patient risk score reassessed
as per trust protocol?
Risk Care plan?
State dates:
Always :
Intermittently:
Never:
Was patient skin condition
documented daily or at each visit?
Status:
Always :
Intermittently:
Never:
Was patient skin assessment
documented daily or at each visit?
Always :
Was a moving and handling
assessment completed?
Intermittently:
Risk Rating;
Never:
Actions Implemented:
Yes
No
26
Was a nutritional assessment
completed?
Yes
No
High risk
Medium Risk
Low Risk
Actions Implemented:
Was a continence assessment
completed?
Yes
No
Actions Implemented:
Was a Photograph, tracing, clinical incident form Regulation 18, adult safeguarding referral completed?
Photograph/tracing
Clinical Incident Form/ Req18
Adult Safeguarding
Not required
27
Preventative Care
Was preventative care planned?
Yes /No
Details
Was preventative care delivered?
Was appropriate equipment used?
Was repositioning of patient
evident?
Patient Management
Does the patient have any of the
following?
Yes/No
Details
Diabetes
Skin condition
Immobility
Vascular disease
Incontinence
Sensory loss
Previous pressure ulcer
Malnutrition
Organ Failure
Anti embolic stockings
Prescribed ?
Measured?
Inotropes (Noradrenaline,
metaraminol,high dose adrenaline)
History of smoking
Epidural
28
Patient Information
Is patient information available in
clinical area?
Yes/No
Details
Is the patient able to receive
pressure ulcer prevention
information?
Did the patient’s relatives /carers
receive information?
Is the patient/carer aware of the
pressure ulcer?
Staff Education
Are the staff aware of the pressure
ulcer guidelines?
Yes/No
Are the staff aware of the pressure
relieving equipment procedures?
Yes/No
Are the staff aware of how to
access these guidelines?
Yes/No
Does the ward / team have a link
nurse?
Yes/No
How many link nurse study days
has the link nurse attended in the
past 12 months?
Yes/No
What is the percentage of staff
that have attended Pressure ulcer
prevention training in the last 2
years?
Yes/No
Details
29
Have the working conditions
(administrative, physical,
environment, work load, time)
had a bearing on the care given
to the patient?
Details:
Have the organisation/strategic
(organisational structure,
priorities, safety culture, financial
restrictions) has an impact on the
care given to patient?
Details:
Local team/ward factors
Individual (physical,
psychological, social, personality)
Details:
Team and social (role
congruence, leadership, support
and cultural factors)
Details:
Communication (verbal, written,
non-verbal)
Details:
30
Please
tick all
that
apply
Section C – Key issues identified
Nutrition
Moving and handling
Continence issues
Lack of skin/risk assessment
Preventative care not implemented
Issues with resources
31
Please
tick all
that
apply
Overall condition of the patient
Non-concordance
Staff education
Other (please specify)
32
Section D – Root causes
Please tick
all that apply
Pressure
Shear
Friction
Moisture
Other (please specify)
33
(How will you make the changes?)
(What changes need to be
made?)
Date completed
solution
(H.,
L)
StartM,
date
Action and steps
Priority
Recommendation/
Person
responsible for
change
Key issues/root causes (list)
How will this action be monitored?
34
When you have completed this process:
Check that each stage has been completed and recorded.
Record the details of other key staff that have participated and ensure they receive feedback on the
outcomes of this investigation.
Name
Designation
Date Informed
Please note that STEIS also needs to be updated with main findings, lessons learnt and closure of this
incident needs to be requested from the SHA by emailing ian.baker@westmidlands.nhs.uk
This document is based on the National Patient Safety Agency “learning through action to reduce
infection” RCA tool and the University Hospital Coventry and Warwick Tissue Viability Team.