Why do patients develop severe pressure ulcers? A retrospective case study

Abstract

ObjectivesThis study focuses on the ways in which the organisational context can influence the development of severe pressure ulcers. Severe pressure ulcers are important indicators of failures in the organisation and delivery of treatment and care. We have a good understanding of patients’ risk factors, but a poor understanding of the role played by the organisational context in their development.SettingThe study was undertaken in six sites in Yorkshire, England. The settings were sampled in order to maximise diversity, and included patients’ own homes, acute hospital medical and surgical wards, a community hospital and a nursing home during a period of respite care.ParticipantsData were collected about eight individuals who developed severe pressure ulcers, using a retrospective case study design. The data sources included interviews with individuals with severe pressure ulcers, and with staff who had treated and cared for them, and clinical notes.Results4 accounts indicated that specific actions by clinicians contributed to the development of severe pressure ulcers. Seven of the 8 accounts indicated that they developed in organisational contexts where (1) clinicians failed to listen and respond to the patients’ or carers’ observations about their risks or the quality of their treatment and care, (2) clinicians failed to recognise and respond to clear signs that a patient had a pressure ulcer or was at risk of developing one and (3) services were not effectively coordinated.ConclusionsPatient accounts could only be partially explained in terms of specific events or sequences of events. The findings support the conclusion that there was general acceptance of suboptimal clinical practices in 7 of the 8 contexts where patients developed severe pressure ulcers.

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

“…It appears that there has been little patient involvement in the process with less than half of the patients who developed a severe PU being interviewed (table 1). Previous research [10] has identified that organisational factors are often key in identifying the root cause; however this was not reflected in this study.…”

“…Previous studies have identified nd to increased risk of PUs [10], however this study did not identify why staff overlooked the patients nutritional needs or the barriers to communication between medical and nursing staff regarding nutrition.…”

“…This study used a retrospective case study design method to produce accounts of individual patients who developed severe PUs. An iterative review, involving reviewers (including patients) with different backgrounds, was used to validate and interpret the accounts [10]. An additional output of the study was to develop a methodology for RCA, suitable for use in current NHS practice.…”

Evde Bakim Hastalarinda Basi Yaralarina Yaklaşim: En Uygun Yaklaşim Koruyucu Heki̇mli̇k

“…Hasta ve hasta yakınlarının yetersiz dinlemek, yetersiz muayene, klinisyenlerin yüksek riskli kişilerde bası yarası bulgularını tanımada yetersizlik, servisler arasında kordinasyonun etkin olmaması nedenleri ile şiddetli bası yaralarının geliştiği görülmüştür (23). Evde sağlık hizmeti, yatağa bağımlı hastaların düzenli muayenesinin yapılması, gereklilik durumunda diğer servislerle koordinasyonun sağlanması açısından önem taşımaktadır.…”

Home pressures: failures of care and pressure ulcer problems in the community – the findings of serious case reviews

“…In a further SCR, Wood (2014) (Pinkney et al 2014). In a small number of localities there were policies and procedures at the time stating that some (severe) or all pressure ulcers should be reported as a safeguarding alert.…”