Investigating your acquired pressure ulcers.

OSKA Pressure Care experts

In all Long-term Health and Care settings in the UK, we are encouraged to report on our acquired harms and report on our findings to the CQC/Care inspectorate, safeguarding leads and governance leads. Rather than this being a process to cross the T’s and dot the I’s it is here you can identify key emerging themes and ensure proposed actions and changes are meaningful and measured.

Having said that if you are new to quality improvement models following incidences it can be a very daunting affair. As clinicians of all levels we are asked to investigate and for you care providers out there you may find you do this naturally.

An emerging theme that has come from all the RCAs I have been involved in over the years is around culture and behaviors of an area of practice. This often feels like opening Pandora’s box, as to challenge in-house behaviors positively can be delicate work. From practice however, the greatest changes I have seen are in well led organisations where whole staff involvement are included.

An example of this I found was sitting in on an infection control meeting in the past where we were discussing how to reduce our infection reduction rate targets in the wards. Many different opinions and ideas were discussed with no consensuses on identifying a single ‘cause’ and ‘action’. Eventually one of the more junior ward nurses had asked why no one had invited the cleaners to participate in the group. After this two of the cleaners were asked if they would like to be infection control champions and participate in the action plans and audits. Although this may seem trivial, the inclusion of this group meant they felt increase value in their role and able to participate in improvement with recognition of their ideas. This may create a snowball effect across an organisation. In very large groups with multi-homes this can take time and it is vital improvements are shared and celebrate across the homes.

If gaps are identified from your RCA, it can be hard initially to know where to start with your improvement plans. We also need to demonstrate that any changes are effective. Tracking your emerging themes, actions next to the number of incidences over time should show the impact of your changes along with staff and resident feedback. All of this may be collected and shown to your inspector on their visits and likely to tick a lot of the key lines of enquiry!

To start this process, you do not need to investigate deep tissue injury’s only, indeed if you have a high number of reported moisture lesions or Category 2 Pressure ulcers, why not start here to deep dive in to your trends and emerging themes.

There are some templates available online to undertake a RCA such as the fishbone diagram you can look up. I have adapted a tool for long term care, if you would like the template either come on the Facebook support page or contact me.

If you would like a ½ day RCA training session for staff or general clinical advice, feel free to get in touch.