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• Pressure injury documentation: the case for using incident reports to inform quality improvement
  Ray Samuriwo
  Published on: 12 April 2018

• Published on: 12 April 2018

  Pressure injury documentation: the case for using incident reports to inform quality improvement

  • Ray Samuriwo, Lecturer School of Healthcare Sciences, Cardiff University, Cardiff, United Kingdom

  Pressure injuries are a largely avoidable adverse patient safety event, which are the focus of considerable global quality improvement efforts. Recent papers by Padula and Pronovost (1) and Squitieri et al. (2) highlight some of the challenges that exist with regards to efforts prevent and reduce the extent of patient harm arising from pressure injuries. These challenges include inconsistent reporting of the extent of pressure injury related harm as evinced by differences in the pressure injury related documentation from different care settings (1, 2) which are thought to be due to financial penalties for nosocomial pressure injuries (1). Padula and Pronovost (1) highlight the fact that the majority of the measurement and reporting of pressure injuries as well as the financial penalties for pressure injuries focus on hospital settings when pressure injury can arise at any point during a patient’s care trajectory. A number of possible solutions are put forward by Padula and Pronovost (1) to avoid underreporting the true extent of pressure injuries and to generate more accurate data that can be used to prevent and reduce the number of patients with pressure injuries in hospitals and other care settings. However, it is worth reflecting on the challenges of measurement and reporting for quality improvement and to considering what other routinely collected pressure injury related data can be used to inform improvement efforts.
  Establishing systems in which patient harm i...

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  Pressure injuries are a largely avoidable adverse patient safety event, which are the focus of considerable global quality improvement efforts. Recent papers by Padula and Pronovost (1) and Squitieri et al. (2) highlight some of the challenges that exist with regards to efforts prevent and reduce the extent of patient harm arising from pressure injuries. These challenges include inconsistent reporting of the extent of pressure injury related harm as evinced by differences in the pressure injury related documentation from different care settings (1, 2) which are thought to be due to financial penalties for nosocomial pressure injuries (1). Padula and Pronovost (1) highlight the fact that the majority of the measurement and reporting of pressure injuries as well as the financial penalties for pressure injuries focus on hospital settings when pressure injury can arise at any point during a patient’s care trajectory. A number of possible solutions are put forward by Padula and Pronovost (1) to avoid underreporting the true extent of pressure injuries and to generate more accurate data that can be used to prevent and reduce the number of patients with pressure injuries in hospitals and other care settings. However, it is worth reflecting on the challenges of measurement and reporting for quality improvement and to considering what other routinely collected pressure injury related data can be used to inform improvement efforts.
  Establishing systems in which patient harm is measured and reported in a manner that underpins improvement in healthcare is challenging for a number of reasons. Firstly, many of the measurement instruments have their limitations with regards to utility and ease of use (3). Many of the harms that are subject to measurement are believed to be preventable but it is often challenging to establish the extent to a specific harm can be prevented (3). Pressure injuries are the quintessence of how challenging it can be to ascertain the preventability of a specific harm as they can be arise through the complex interplay of different factors at any point in the patient’s care continuum. The measurement of harm in healthcare is a social practice that is undertaken in complex adaptive system in which a number of organisational contextual, organisational and human factors are at play. The impact of these factors is epitomised by the fact that a focus on measuring harm can have unintended consequences such as gaming and effort substitution (3, 4) which undermine improvement efforts. In addition, measurement systems are often calibrated to report past harms and so provide a limited but important insight into contemporary patient safety (3).
  In light of the challenges of measurement, it is important to consider what other sources of routinely collected data can be used to underpin pressure injury related quality improvement efforts. For example, pressure injury related patient safety incident reports often contain ‘soft data’ which helps to identify the human, causative and contributory factors give result in adverse events (5). Therefore, patient safety incident reports provide valuable soft data into aspects of harm that can exist beyond of formal measurement systems and may constitute fugitive knowledge. The analysis of patient safety incident reports has been shown (5) to be an effective way of informing national and population level improvement efforts because patient safety incident reports provide unique insights into the factors that give rise to adverse event which are often overlooked at a local level. It may astute to combine the ‘soft data’ and soft intelligence that can be obtained from pressure injury related patient safety incident reports and other sources with the hard data obtained through formal measures of harm to inform quality improvement interventions.
  References
  1. Padula WV, Pronovost PJ. Addressing the multisectoral impact of pressure injuries in the USA, UK and abroad. BMJ Quality & Safety. 2018;27(3):171-3.
  2. Squitieri L, Ganz DA, Mangione CM, Needleman J, Romano PS, Saliba D, et al. Consistency of pressure injury documentation across interfacility transfers. BMJ Qual Saf. 2018;27(3):182-9.
  3. Dixon-Woods M. Measuring what matters: how can we know we are delivering prudent healthcare? Saving 1000 Lives Wales; Cardiff: Saving 1000 Lives Wales Available from: http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/marydixon... 2014.
  4. Kelman S, Friedman JN. Performance Improvement and Performance Dysfunction: An Empirical Examination of Distortionary Impacts of the Emergency Room Wait-Time Target in the English National Health Service. Journal of Public Administration Research and Theory. 2009;19(4):917-46.
  5. Samuriwo R, Williams H, Cooper J, Carson-Stevens A. Improving skin care through data: a pitch for patient safety incident reporting. Journal of Wound Care. 2016;25(12):691

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  Conflict of Interest:
  None declared.

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