Mismanagement of Wounds and Pressure Injuries

Impaired wound healing is associated with a variety of contributing factors such as the presence of infection, pre-existing metabolic conditions, immunosuppression, and radiation treatments. When wound healing is disrupted, chronic healing delay can develop. Three of the most common risks associated with wound-related litigation are failure to follow wound pressure protocol, ignoring wound care best practices, and the presence of retained foreign items.
Healthcare acquired pressure injuries 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, pressure injuries continue to contribute to substantial client harm and extended lengths of stay. In 2015 stage III and IV healthcare acquired pressure injuries were 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 & Health Quality Ontario, 2015). Considered to be highly preventable, pressure injury claims are typically challenging to defend. Timely screening, regular skin integrity assessments, access to specially trained healthcare professionals, and standardized treatment protocols are key to managing this risk.

Expected Outcomes

Adopt current evidence-based protocols for:
o        Wound management;
o        Pressure injures prevention and management.

Implement formal strategies to develop and maintain a work environment which supports client safety and psychological safety.

Adopt best practice quality indicators for wound management and pressure injuries.

Definitions and Acronyms

• CCU – complex continuing care
• Client – includes all persons who receive healthcare and related services including patients, residents and persons in-care
• ED – emergency department
• HAPI – healthcare acquired pressure injuries
• MRP – most responsible practitioner, often a midwife, nurse practitioner or physician

Common Claims Themes and Contributing Factors

Organizational

• Utilization of care providers (employed and contracted) with unknown experience or knowledge in wound management and / or pressure injury prevention and management.
• Lack of current evidence based:
  • Wound management protocols;
  • Pressure injury prevention and management protocols.
• Lack of triage / priority system for assignment of pressure relieving devices / surfaces.
• Lack of a formal system to track serious wound deterioration and pressure injuries.

Knowledge and Judgement 

• Failure to follow MRP orders for wound care and related dressing changes.
• Failure to develop a holistic wound and / or pressure injury prevention and management plan that includes:
  • Defined wound care goals;
  • Alternative methods of wound treatment;
  • Risk factors that could impede wound healing.
• Lack of consideration of risk factors for wound deterioration or pressure injuries.
• Delayed and absent involvement of skin and / or wound care specialists where indicated.
• EDs
  • Failure to screen, assess, and / or documenting findings related to
    • Skin breakdown;
    • Wounds;
    • Pressure injuries.

Documentation

• Inadequate charting-by-exception practices.
• Inadequate documentation of wound management and pressure injury preventive interventions including (but not limited to):
  • Skin assessment, frequency, and relevant findings;
  • Wound size measurements;
  • Dressing changes and observations, treatments, and their effectiveness;
  • Items added or removed from the wound (including type, length and number of gauze, packing, and / or steristrips);
  • Repositioning of client and use of support surfaces;
  • Client, family, and caregiver concerns and education;
  • Routine preventive measures (e.g., turning);
  • Care plans implemented;
  • Discharge teaching and instructions.

Communication

• Inadequate communication of at-risk client, deteriorating wound status, or pressure injury during client handovers, transfers, and discharges.
• Delayed notification of material changes to skin status, wound status, or pressure injury to the MRP.

Mitigation Strategies

Care Processes

• Implement a standardized evidence-based wound management protocol and wound documentation tool (British Columbia Provincial Nursing Skin & Wound Committee, 2020) (Canadian Home Care Assocation, 2012) (Orsted HL, 2017) (Nova Scotia Health, 2021). 
• Implement a standardized evidence-based pressure injury prevention protocol and documentation tool (Canadian Patient Safety Institute, 2021) (Registered Nurses' Assocation of Ontario, 2005) (Registered Nurses' Assocation of Ontario, 2016) (Health Quality Ontario, 2017).
• Implement formal strategies to prevent unintentional retained wound packing; ensure wound and pressure injury documentation tools encourage the recording of the type and quantity of packing removed and inserted (British Columbia Provincial Nursing Skin & Wound Committee, 2020) (British Columbia Provincial Nursing Skin & Wound Committee, 2019) (Registered Nurses' Assocation of Ontario, 2016).
• Implement formal strategies to encourage the inclusion of skin integrity, wound and pressure injury assessments and reassessments into individualized care plans at admission and during care transitions.    

Safety Culture

• Implement formal strategies to develop and maintain a work environment which supports and expects:
  • Intra- and inter-professional collaboration and collegiality;
  • Zero tolerance of intra- and inter-professional bullying and intimidation;
  • Assertive and respectful questioning and challenging of unsafe practices.
• Adopt a standardized, formalized, and program-specific chain of command (escalation) protocol for the rapid escalation of unresolved care concerns or disagreements related orders, decisions, and / or unsafe practices.

Team Training and Education

• Implement formal strategies to support and enhance the team’s clinical knowledge, skills (technical and non-technical), and practical experience surrounding the prevention, recognition, and response to skin deterioration, wound deterioration, and pressure injuries including (but not limited to), scheduled interprofessional and cross-department skill drills and simulations (Canadian Home Care Assocation, 2012) (Health Quality Ontario, 2017).
• Ensure the team training and education strategies address or involve: 
  • Wound staging;
  • Advance wound therapies (e.g., negative pressure wound therapy);
  • Care providers, program areas, or sites with limited practical experience with skin assessments, wound management, and pressure injuries;
  • Unregulated care providers, locums, travel, agency, contracted care providers in addition to regulated health professionals.
• Develop and provide the necessary resources to a core interdisciplinary healthcare team to develop expertise in wound management and pressure injury assessment, management, and treatment modalities (Nova Scotia Health, 2021) (Health Quality Ontario, 2017). 

Equipment, Supplies and Technology

• Implement formal strategies to ensure a sufficient number and type of functioning pressure relieving and redistributing equipment and devices based on client acuity and volumes (Registered Nurses' Assocation of Ontario, 2016) (Health Quality Ontario, 2017).
• Implement a triage protocol for pressure redistributing devices (e.g., beds, mattresses, heel guards).

Documentation 

• Adopt standardized best practice records and / or forms to track skin assessments, wound care and pressure injury progression, treatment effectiveness, and ongoing assessments.

Additional Considerations

Examples of elements to be documented to related to all skin integrity, wounds and pressure injury assessments and re-assessments:

• Date and signature of the person performing the assessment and re- assessment;
• Interventions performed in response to changes to the skin, wound or pressure injury or status (documenting ‘routine care’ is not sufficient);
• Shared decision making (informed choice-informed consent) discussions with clients or substitute decision makers who choose not to follow the care plans or prevention strategies encouraged by the healthcare team.

• Implement strategies to support adherence to documentation practice expectations related to skin assessment, wound, and pressure injuries, specifically related to:
  • Wound deterioration and pressure injury progression;
  • Counts of items removed and inserted into wounds.

Communication

• Implement formal strategies to support the timely communication of significant changes in skin condition, wound condition, or pressure injury to the MRP.

Client and Family-Centered Care    

• Incorporate clients and families in wound care and pressure injury prevention, management, and discharge planning.
• Adopt standardized education, training, and discharge instructions for clients and families that includes (but is not limited to):
  • Their role in the early detection and management of wound deterioration and pressure injuries;
  • Risk factors;
  • Signs, symptoms, and specific instructions for seeking care or notifying the team (Health Quality Ontario, 2017).
• Implement strategies to enable access to interpreter services during education, training, and discharge instructions when needed.

Monitoring and Measurement    

• Adopt a standardized, interdisciplinary, collaborative and evidence-based protocol for conducting quality of care reviews involving wound deterioration and pressure injuries (Incident Analysis Collaborating Parties, 2012) (Machen, 2023); incorporate system thinking and human factors concepts into the review process.
• Adopt standardized best practice quality indicators for:
  • Wound management;
  • Pressure injuries (British Columbia Provincial Nursing Skin & Wound Committee, 2020) (Health Quality Ontario, 2017) (Canadian Home Care Assocation, 2012).
• Incorporate learning from local, provincial, and national wound management incidents and data into local protocols as well as staff and client education and training.

References

• British Columbia Provincial Nursing Skin & Wound Committee. (2019). Wound Assessment &Treatment Flow Sheet: Documentation Guide. Retrieved May 13, 2023, from https://www.clwk.ca/get-resource/wound-assessment-documentation-guide-landscape-4pg/
• British Columbia Provincial Nursing Skin & Wound Committee. (2020). Guideline: Assessment and Treatment of Wound Infection. BC. Retrieved May 13, 2023, from https://www.clwk.ca/get-resource/wound-infection-guideline/
• Canadian Home Care Assocation. (2012). Evidence-Based Wound Care Home Care Perspective. Retrieved May 13, 2023, from https://cdnhomecare.ca/wp-content/uploads/2020/03/Wound_Management_-_Home_Care_Perspective_-_English_2012.pdf
• Canadian Patient Safety Institute & Health Quality Ontario. (2015). Never Events for Hospital Care in Canada. 
• Canadian Patient Safety Institute. (2021). Hospital Harm Improvement Resource Pressure Ulcer. Retrieved May 13, 2023, from https://www.patientsafetyinstitute.ca/en/toolsResources/Hospital-Harm-Measure/Documents/Resource-Library/HHIR%20Pressure%20Ulcer.pdf
• Health Quality Ontario. (2017). Patient/Resident Reference Guide Pressure Injuiries Care for Patients in All Settings. ON. Retrieved May 13, 2023, from https://www.hqontario.ca/Portals/0/documents/evidence/quality-standards/qs-pressure-injuries-patient-guide-en.pdf
• Health Quality Ontario. (2017). Pressure Injuries Care for Patients in All Settings. Toronto ON.
• Incident Analysis Collaborating Parties. (2012). Canadian Incident Analysis Framework. Edmonton AB. Retrieved May 13, 2023, from https://www.patientsafetyinstitute.ca/en/toolsResources/IncidentAnalysis/Documents/Canadian%20Incident%20Analysis%20Framework.PDF
• Machen, S. (2023, 5). Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. BMJ Open Quality, 12(2), e002020.
• Nova Scotia Health. (2021). Nova Scotia Skin Integrity and Wound Care Standards of Care. Retrieved May 13, 2023, from https://policy.nshealth.ca/site_published/nsha/document_render.aspx?documentRender.IdType=6&documentRender.GenericField=&documentRender.Id=92257
• Orsted HL, K. D.-L.-D. (2017). Best practice recommendations for the prevention and management of wounds. Retrieved from https://www.woundscanada.ca/doclink/wc-bpr-prevention-and-management-of-wounds/eyJ0eXAiOiJKV1QiLCJhbGciOiJIUzI1NiJ9.eyJzdWIiOiJ3Yy1icHItcHJldmVudGlvbi1hbmQtbWFuYWdlbWVudC1vZi13b3VuZHMiLCJpYXQiOjE2NDIwOTcxNzYsImV4cCI6MTY0MjE4MzU3Nn0.vNrzDRzVNQtAFxbTkudijK_
• Registered Nurses' Assocation of Ontario. (2005). Risk Assessment and Prevention of Pressure Ulcers. Toronto ON. Retrieved May 13, 2023, from https://rnao.ca/sites/rnao-ca/files/Risk_Assessment_and_Prevention_of_Pressure_Ulcers.pdf
• Registered Nurses' Assocation of Ontario. (2016). Assessment and Management of Pressure Injuries for the Interdisciplinary Team, Third Edition. Toronto: Registered Nures' Assocation of Ontario. Retrieved May 13, 2023, from https://rnao.ca/bpg/guidelines/pressure-injuries