Stage III and IV pressure ulcers have been added to the list of hospital-acquired conditions whose treatment will no longer be reimbursed by Medicare. Pressure ulcers are also on the list of “Never” events, or incidents that should never occur at healthcare facilities, and can lead to serious complications from 
patients who suffer from them. It is imperative that healthcare facilities reduce the risk of patients contracting pressure ulcers.
To reduce the risk of pressure ulcers, a root cause analysis can be performed. Not only can we use root cause analysis to determine the causes of incidents that HAVE occurred at our facility, we can outline the ways incidents COULD occur, or, in this case, what is required for a patient to contract pressure ulcers. For this, we use a proactive Cause Map (or visual root cause analysis).
We start our analysis by examining the impact to the goals. There are many impacts to the goals, but we will just focus on two: the patient safety goal is impacted by a patient contracting a stage III or IV pressure ulcer, and the compliance goal is impacted because this is a “never” event. To continue the Cause Map, we ask “What caused this?” and put the answer to the right. So when we ask “What caused the pressure ulcer?” we write “Death of tissue.” We then continue through the Cause Map this same way.
Death of tissue is caused by poor skin condition and mechanical damage to the tissue. Poor skin condition can be caused by a number of things, including poor environment, contaminants on the skin, and inadequate nutrition.
There are three types of mechanical damage to skin that causes pressure ulcers. These are shear, friction, and pressure injuries. Shear injuries can be caused by the head of a patient’s bed being elevated (so that the skin pressed against the bed is damaged as the rest of the body tends to be pulled downwards by gravity). Friction injuries can be caused by skin being drug over skin linens (to reposition an immobile patient, for example) or by bony prominences (such as knees and ankles) contacting each other. Pressure injuries are generally caused by a patient remaining in the same position. Causes of this are lack of knowledge about pressure ulcers, and being unaware of a specific patient’s risk.
There is more detail that can be added to this root cause analysis, but for the purposes of this example we will stop here and begin looking at solutions. Any cause box on the map can have a solution, or several solutions, but not every box will have a solution. Some solutions that have been compiled from various resources are shown in green boxes. Both the Cause Map and solutions can be broken out into more detail, depending on the needs of the organization.
Click on “Download PDF” above to download a PDF showing the Cause Map.
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