Healthcare Acquired Pressure Injuries

Service: Risk Management
Subject: Care
Setting: Wounds

Healthcare acquired pressure injuries (HAPI) are localized damages to the skin and/or underlying soft tissue, usually over a bony prominence, resulting from compression of the capillaries supplying the skin and subcutaneous tissues, leading to tissue necrosis. Despite education and preventative efforts, HAPI continue to contribute to substantial patient harm and extended lengths of stay. In 2015 stage III or IV HAPI was recognized as one of Canada’s “never events” (defined as “patient safety incidents that result in serious patient harm or death that are preventable using organizational checks and balances”, Canadian Patient Safety Institute and Health Quality Ontario. (2015). Considered to be highly preventable, HAPI claims are typically challenging to defend. Screening, regular skin integrity assessments and standardized treatment protocols are key to managing this risk.

Common Claim Themes


  • Claims involving interdepartmental, or multi-organizations participation (e.g., surgical team/ hospital, rehabilitation facility and case coordinator/home care agency).
  • Lack of established pressure injury prevention protocols to enable repositioning at regular intervals.
  • Lack of triage/priority system for assignment of pressure relieving devices/surfaces.
  • Lack of a formal system to track pressure injuries

Knowledge and judgement

  • Failure to screen and/or assess for skin breakdown at the time of admission, following clinically significant status changes or transitions of care.
  • Lack of response to patient and family concerns. 
  • Procedures and care plans that are not informed by current evidence or care plans that are designed to be the domain of a single discipline, instead of a shared obligation among a multidisciplinary team.
  • Lack of consideration of risk factors for developing pressure injuries (e.g., mobility, obesity, level of consciousness). 
  • Delayed and/or absent involvement of skin care specialists (dermatologist, nutritionist, wound care expert) where indicated.
  • Delayed and/or absent involvement of dietitian.

Documentation and communication

  • Inadequate communication of at-risk status during patient handoffs, transfers and discharges.
  • Delayed notification of material changes to skin or wound status to the most responsible practitioner.
  • Poor charting-by-exception practices.
  • Lack of documentation of preventive interventions such as:
    • Repositioning of patient and use of support surfaces;
    • Patient, family and caregiver education;
    • Routine preventive measures (e.g., turning);
    • Care plans implemented;
    • Treatments and their effectiveness;
    • Presence of stage I and II HAPI.

Case Study 1

An elderly patient was admitted to hospital from a nursing home for treatment of lateral ankle pressure injuries. At the time of admission, the patient was assessed to be at low risk for the development of pressure injuries despite risk factors (preexisting pressure injury, limited mobility, and urinary incontinence). The patient was discharged to the nursing home three weeks later with a sacral and heel ulcers. Expert review of the hospital’s nurses was not supportive, noting that the team did not complete a skin breakdown assessment, initiate preventive interventions such as a special mattress, use barrier creams, or consult with a nutrition expert or wound specialist. Further, experts were critical of the team’s failure to incorporate the patient evolving risk factors into the care plan, including the need for more frequent turning and hydration.

Case Study 2

A young patient with quadriplegia was admitted to a rehabilitation centre during which the patient sustained a sacral pressure injury. Unable to move independently or request changes in position, the patient was reliant on others for frequent repositioning and skin integrity assessments. A patient care plan was developed incorporating the HAPI risk factors. By the time of discharge, the ulcer progressed to a stage IV injury. Expert review was unable to provide a supportive opinion as there was no documented evidence in the health record that the nurses followed the care plan, including the need for re-positioning the patient regularly and monitoring for pressure injuries. The standard of care of team members was deemed indefensible.

Mitigation strategies

Reliable Care Processes

  • Implement a standardized evidence-based pressure injury prevention program or strategy that includes:
    • A standardized evidence-based pressure injury risk assessment tool to assist with detecting existing pressure injuries and to determine patients at-risk for skin breakdown; 
    • Standardized terminology for pressure injury staging;
    • Implement strategies to ensure results inform individualized care plans;
    • Performance of skin and pressure injury assessments at all transitions of care (e.g., at first presentation and/or admission, shift change, transition to external facility and discharge).
  • Implement formal strategies to ensure results from assessments and reassessments are incorporated into individualized care plans at admission and transitions (e.g., repositioning, managing moisture on skin, mobility and activities, hydration and nutrition, minimizing pressure, shear and friction, support surfaces and equipment).
  • Consider implementation of periodic, healthcare team grouped patient care activities that enable completion of multiple preventive measures during one encounter (e.g., Pain Elimination and Position (PEP) rounds).
  • Implement strategies to support and encourage access to expert staff or teams for treating and discussing complex pressure injury cases.


  • Implement formal multifaceted and targeted safety strategies to support and enhance teams’ clinical acumen surrounding the prevention, recognition and response to pressuring injuries (e.g., in-situ simulations and skills drills; sharing of learnings and trends from periodic chart audits and extracts, analysis of reported incidents, and medical-legal matters).

Documentation and Communication

  • Adopt a standardized record or form to track pressure injury staging, treatment effectiveness and ongoing assessments.

Strategies for nurses and unregulated care providers

  • Ensure any changes in skin condition for at-risk patients is communicated to the most responsible practitioner in a timely manner.
  • Ensure complete and timely documentation of all skin and pressure injury assessments/re- assessments including (but not limited to):
    • Date and signature of the person performing the assessment/re-assessment;
    • Interventions performed in response to changes to skin integrity or wound status (documenting ‘routine care’ is not sufficient);
    • Informed consent discussions with patients who choose not to follow the prevention strategies encouraged by the healthcare team.

Patient and Family-Centered Care

  • Incorporate patients and families in care and discharge planning.
  • Develop (or co-develop with patient and family advisors) an education program for patients and families regarding prevention and management of pressure injuries including (but not limited to):
    • Their role in the early detection and management of pressure injuries (e.g., agitation, pain, incontinence);
    • Risk factors, prevention, warning signs and symptoms to be aware of;
    • The importance of communicating risk factors, symptoms etc. to the healthcare team, most responsible and/or primary community practitioner.


  • Implement formal safety strategies to ensure a sufficient number and type of functioning pressure relieving and redistributing equipment and devices for patient acuity and volumes.
  • Implement a triage protocol for pressure redistributing devices (e.g., beds, mattresses, heel guards).

Post Incident Management

  • Ensure timely internal notification (e.g., clinical leaders, risk manager), documentation, external notification (where required), disclosure, and investigation of serious healthcare acquired pressure injuries (or as defined by legislation).

Monitoring and Measurement

  • Implement formal strategies to monitor and measure the effectiveness and efficiency of, and adherence to, pressure injury prevention and management protocol, algorithm and checklist(s), including (but not limited to): 
    • Adoption of formal program and site-specific quality indicators (e.g., proportion of patient with documented evidence that a skin/pressure injury assessment was completed within 24 hours of admission; compliance pressure injury tracking tool); 
    • Sharing of learnings from near-misses and harm incidents (e.g., chart audits, trigger tools, incident reports, team debriefs, critical incident and quality of care and quality improvement committee reviews, medical legal claims, coroner reports and related recommendations, provincial advisory reports).


  • HIROC claims files.
  • Accreditation Canada. (2017). Required organizational practices handbook 2017: Version 2-January 2017.
  • Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals: A toolkit for improving quality of care.
  • Canadian Patient Safety Institute and Health Quality Ontario. (2015). Never events for hospital care in Canada: Safer care for patients. 
  • ECRI Institute. (2018). Pressure injuries. Healthcare Risk, Quality, & Safety Guidance.
  • ECRI Institute. (2019). Photograph wound documentation. Healthcare Risk, Quality, & Safety Guidance.
  • Health Quality Ontario (n.d.).Quality standards: Pressure injuries: Care for patients in all settings.
  • Institute for Clinical Systems Improvement. (2012). Health care protocol: Pressure ulcer prevention and treatment protocol. (3rd Ed.).
  • Institute for Healthcare Improvement. (2011). How-to guide: Prevent pressure ulcers. Tools.
  • National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. (2014). Prevention and treatment of pressure ulcers: Quick reference guide. (2nd Ed.).
  • Padula V, Pronovost J, Makic F, et al. (2018) Value of hospital resources for effective pressure injury prevention: A cost-effectiveness analysis. BMJ Qual Saf. 28(2):132-141.
  • Popovich K, Tohm P, Hurd T. (2010). Skin and wound care excellence: Integrating best- practice evidence. Healthcare Quarterly, 13:42-46.
  • Registered Nurses’ Association of Ontario (RNAO). (2011). Risk assessment and prevention of pressure ulcers. Nursing best practice guideline.
  • Sendelbach S, Zink M, Peterson J. (2011). Decreasing pressure ulcers across a healthcare system: Moving beneath the tip of the iceberg. J Nurs Adm. 41(2):84- 89.
  • Sullivan N, Schoelles M. (2013). Preventing in-facility pressure ulcers as a patient safety strategy: A systematic review. Ann Intern Med. 158(5 Part 2):410-416.
  • Unsworth N, Johnson D, Kuchta B, (2011). Successful implementation of a professional development program for: Wound care in the community care setting. Healthcare Quarterly, 14(1):88-94.
  • Webster J, Coleman K, Mudge A, Marquart L, et al. (2011). Pressure ulcers: Effectiveness of risk-assessment tools. A randomized controlled trial (the ULCER trial). BMJ Qual Saf. 20(4):297-306