Indicators of Patient Safety and Service Quality

This article discusses the different indicators of patient safety and service quality in healthcare organizations, with a focus on decubitus ulcers. It also provides a literature review and a PDSA cycle for improving patient safety. Subject: Healthcare, Course Code: N/A, Course Name: N/A, College/University: N/A

Running head: INDICATORS OF PATIENT SAFETY AND SERVICE QUALITY
INDICATORS OF PATIENT SAFETY AND SERVICE QUALITY
Name of the student:
Name of the university:
Author note:

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INDICATORS OF PATIENT SAFETY AND SERVICE QUALITY
Introduction:
Patient safety indicators can be defined as the set of measures that help in screening for
the different adverse events that the service users experience as a result of the exposure to the
healthcare systems. Researchers are of the opinion that these events are likely to be amenable to
prevention by altering and changing working procedures at the provider or the system level. Two
different types of indicators are used by organizations to analyze the levels of patient safety and
patient quality maintained in the healthcare organizations (Zubkoff et al., 2016). The first one is
the provider level indicators and the other one is the area-level indicators. The assignment will be
mainly based on one of the examples of provider level indicators called the decubitus ulcers.
Occurrence of the hospital acquired decubitus ulcers can help in reflecting the kind and quality
of the care that the professionals are proving to the patient (Goudie et al., 2015). The assignment
will show how occurrence of such ulcers not only cause suffering to the patient and affect their
satisfaction but will show how they can act as indicators that evidence based high quality care is
missing in the healthcare organization.
Brief overview of the indicator:
Provider level indicators are seen to provide a measure of the various types of potentially
preventable complications for the patients who have received their initial care as well as facing
the complications of the care within the same hospitalization. Researchers are of the opinion that
these forms of indicators include only those cases where the secondary diagnosis code flags
potentially preventable complication (Stalpers et al., 2015). The Australian Commission on
Safety and Quality in Healthcare have given a list of about 16 hospital acquired complications

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which act as indicators for patient safety maintained in the healthcare organizations. Pressure
injury had been identified in the list of 16 complications as one of the indicators of patient safety.
A pressure injury has can be defined as the localized injury to the skin as well as in the
tissue that underlie the skin usually in the regions that remain on the bony prominence. It mainly
occurs because of the pressure or that remains in association with friction as well as shear. This
indicator of the hospital acquired complication is seen to include stage III ulcer, as well as in
stage IV ulcer as well as unspecified presence of pressure ulcer and other such areas (Van et al.,
2016).
It might raise a concern as to how it can indicate that the patients were not taken good
care or that the care which was taken was not of adequate quality ensuring safety of the patients.
It might also raise a concern as to how much prevalent this issue is, so that it gets the title of an
indicator or poor quality care. Each year, the patients in the nation of Australia are seen to
experience incidences of various pressure injuries. Data of about 4313 cases of pressure injuries
have been found in the Australian public healthcare centers. This data had been reported in 2015-
2016. The rate of the healthcare associated pressure injuries in the Australian healthcare centers
was seen to be 9.7 injuries per 10000 hospitalizations in 2015-2016 (Bredesen et al., 2015).
Pressure injuries are seen to take long time in healing and this has negative consequences
on the quality of life of the patients. The injuries are known to cause severe pain and can also
include severe pain and even different types of disturbances in mood as well as vulnerability to
different forms of infection. Researchers are of the opinion that this issue also adversely affects
the rehabilitation, mobility and even long term quality of care (Fabruzzo et al., 2016). Pressure
injury prevention is therefore seen to present an important challenge mainly in the acute care

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settings. Data collected had revealed that different strategies are present for reduction of the
occurrences of this disorder. However, the practices are not used in a systematic manner in the
hospitals.
Hospital acquired pressure injuries have many negative effects on the lives of the patients
as well as results in wasting of healthcare resources which could have been saved and used for
other needy patients. It extends the length of hospitalization of the patients which impact the
patient physically and mentally and the families emotionally (Moore et al., 2017). These pressure
injuries can result in increased cost of the admission that is in turn incurred by the healthcare
services. This additional expenditure can be the attributed to the increase in the length of the stay
as well as many other complex necessities and needs. Although there is increased economic cost,
the most important cost is mainly the different degrees of pain as well as the discomfort
experienced by the patients.
Literature review:
Decubitus ulcers are one of the indicators of patient safety and service quality provided
by the nursing professionals. This is form of injury which occurs to the skin and the tissues that
underlines the skin. Studies suggest that this form of cancer mainly occurs by the application of
pressures specifically to certain bony parts of the bodies of patients (Chabboyer et al., 2018).
This form of ulcers can occur due to weight of the body, medical devices as well as lack of
movement of the body. Researchers are of the opinion that bony areas that do not have fat or
muscles under the skin are more likely to develop Decubitus ulcers than those areas that have
fats and muscles (Cox et al., 2015).

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Studies by Bharucha et al. (2018) have suggested that patients who have undergone
surgeries are in particular more prone to development of Decubitus ulcers. This is mainly
because they are kept in one particular position for an extended period, where they are unable for
movement during the entire procedure. Studies have shown that Decubitus ulcer rates are more
common in surgery patients who are sedated because of anesthesia or those who have lost the
ability to move or can move very little. In comparison, surgery individuals who are awake and
are feeling pain or discomfort in particular position when lying in one position for too long can
respond to such sensation by summoning nurses or by moving and adjusting their body positions.
However, such options might not be available for critically ill patients who are sedated,
paralyzed or have lost their ability to move their body from their own self after surgery.
Johnston (2016) has said that Hospital acquired pressure ulcers can denote the improper
care service delivery by the nursing professionals, showing breaches of bioethical principles of
beneficence and non-maleficence. After surgery, prevention of the pressure ulcers is indeed one
of the important responsibilities of the healthcare professionals. Nurses need to identify patients
who might be at the higher risk for skin injuries and out preventive measures to prevent the
occurrence of the pressure ulcers. Nurses need to be well skilled for frequent turning of the
patients who are unable in getting out of the bed or turn themselves after they had gone through
sever and critical surgeries. Studies by Kronick et al. (2016) have also proposed that nurses can
also pad the feet, ankles and even other bony areas when the patient remains at an increased risk
for skin damage. Present evidence based studies also recommend using of special beds that can
be utilized for the reduction of the formation of the pressure ulcers.
Many of the researches have put importance on the fact that nurses need to be aware of
the risk factors that can increase the chances of the surgery patients to develop the Decubitus

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ulcers. Although, inability of the surgery patients to move frequently is one of the most
important risk factor for the development of the ulcers, other risk factors are also present which
post-operative care nurses need to be aware (Cutting et al., 2015). Patients who suffer from
diabetes also remain at an increased risk of bedsores. Other risk factors that also increase the
chances of hospital-acquired Decubitus ulcers are total time in the operating room that might
include multiple surgeries. Older patients after surgery also remain at an increased risk in the
development of such forms of ulcers. Moreover, use of medications called the vasopressors that
help in increasing the blood pressure also increases the chances of the risk factors for
development of the ulcers. Higher risk on the Braden scale which is actually a tool used for
determination of the patient’s risk level as a surgical candidate also act as one risk factor
(Webster et al., 2017). It has been also identified that low body mass index is another risk factors
for the occurrence of Decubitus ulcer in the surgery patients. Thinner patients are seen to be at a
higher risk as they are seen to be more “bony” and less “fluffy”.
During the period of immobility that patients experience during the time of surgery, the
body starts reacting as if the patient had already been on the bed rest. Studies have shown that
during this time, blood vessels enlarge which results in fluid loss as well as in blister formation.
Patients also remain immobile immediately afterward in recovery. This might makes the
symptom worse (Recio et al., 2018).
One of the most common behaviors of the professional has been noted down by one
journal article. Researchers are of the opinion that the professionals are not thinking about how
they can keep patients away from developing decubitus ulcers. This is mainly due to the fact
because they think that they cannot develop ulcers until hours or days after they have been
immobile after the surgery. This viewpoint makes them careless about the assessment they need

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to make regarding identification of the patient about his risks for developing decubitus ulcers.
The researchers are of the opinion that pressure injuries of the patients can be attributed to recent
surgeries anywhere from 5% to that of 53% over the time (Linton et al., 2016). Therefore, there
remains an additional responsibility of the healthcare professionals when the patients have
already gone surgery. This is to identify if the patients are at the higher risks for development of
such ulcers and accordingly take precautions and initiatives.
Another article by Griffiths et al. (2016) speaks about the importance of the surgeons to
monitor the patients who are scheduled for surgeries lasting three hours or more. They should
also monitor the patients who have experienced trauma and those who are in prone positions.
Moreover the researchers have also stated that there are some forms of surgeries which are more
likely to make the patient develop decubitus ulcers than the others. These surgeries are cardiac,
bariatric, vascular, and orthopedic as well as transplant surgeries. Hence, the professionals who
would be caring for patients with such surgeries need to be careful about monitoring them and
providing them with sufficient resources and interventions for prevention of the disorders.
PDSA cycle:
This is a scientific method used for action oriented learning. Once a team gas set its aim,
established its membership and develops measures for determining whether the change leads to
an improvement, the next step is to test the change in real work setting. For this, PDSA cycles
are used. The Plan-Do-Study-Act (PDSA) cycle is mainly shorthand for testing a particular
change. The steps are planning it, trying it, observing the various results that are obtained and
acting accordingly on what is learned (de Almeida Medeiros etb al., 2018).
First PDSA cycle:

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Plan: In order to ensure patient safety, change in organizational climate that supports safe and
high quality services is important. Therefore, it is important to modify the environment for
improving patient safety and care quality for reduction of the prevalence rates of the decubitus
ulcers in the healthcare. Therefore, alteration of the healthcare environment and development of
better organizational climate is important for supporting quality care to patients reducing
pressure ulcers.
Do: In order to improve the environment for safety, different types of initiatives need to be taken.
This includes implementing of different technical changes like that of the electronic medical
record systems which would contain all patient information and give idea whether the patient
might be vulnerable o pressure ulcers (Lavallie et al., 2018). The risks would be noted in medical
records that help nurses to identify the vulnerability of patients. Moreover, such technologies
will help the team members during active delegation so that next shift nurses can follow the
protocols of turning the patients on a timely basis. Moreover changing the organizational climate
would involve improvement of staff awareness of patient safety risks. Moreover, the
organizational culture of following evidence based approaches for reduction of the risks of the
adverse events of the exposure to hospital acquired complications. Working with multiple
departments for collaboration, coordination and redesigning care should be also included.
Study: a monitoring team would be developed who would be taking rounds everyday and note
down important information regarding handling of the technologies, staff awareness
development, following of the culture of evidence based practices and team actions for
redesigning care. A report would be developed on their observation and it would be found out
how the four aspects are being carried out for the prevention of hospital acquired complications
of pressure ulcers.

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Act: following the data obtained from the report of the monitoring team, initiatives would be
taken for betterment of organizational climate development that would ensure safety and provide
strategies for prevention of pressure ulcer development.
Second PDSA cycle:
Plan: it is important for the nursing professionals to develop the knowledge and skills by which
they can correctly identify the vulnerable individuals and accordingly set interventions and
prevention plans for stopping occurrence of pressure ulcers. Hence training sessions for them
would be planned with stalwart healthcare trainers
Do: the conference halls in the healthcare organization can be used in the training sessions and
the nursing professionals would be requested to take out 1 hour of their work schedules three
times a week for three weeks. Discussion sessions would be also arranged among the nurses and
their mentors (Palfreyman & Stone, 2015). Following this, mentors need to guide the nurses in
practical sessions and provide them with scores. Also the nurses would be requested to fill in
feedback forms after each training sessions
Study: the feedback forms filled in by the nurses would be analyzed by the health care project
managers. Moreover, the scores which are provided by the mentors over the practical and
theoretical knowledge exhibited by the nurses would also help to know how well they have
developed their knowledge and skills in identification and prevention of the hospital acquired
pressure ulcers
Act: after analyzing the data, if it is found that training sessions are becoming fruitful for the
development of the knowledge and skills of the nurses and they are able to correctly identify and

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take preventive measures for the stopping of occurrence of pressure ulcers, then the training
sessions can be also arranged on a bigger scale.
Third PDSA cycle:
Plan: one of the most important initiatives that need to be taken is to develop a policy and
guideline protocol that would govern the action of the nurses and would help them to follow a
particular framework ensuring prevention of pressure ulcers. One would be the guidelines that
would guide the nurses for prevention of the pressure ulcer occurrences. The other would be the
policy framework which would include the different penalty systems that would be imposed in
breaching of quality care to the patients.
Do: policy makers, healthcare researchers and healthcare managers should research and discuss
the different aspects of the prevention strategies of pressure ulcers in details and accordingly
develop policies, guidelines and frameworks (Johnson et al., 2016). Feedback forms will be
circulated among different hierarchical levels of the healthcare systems in order to get the
response of how such policies and guidelines would be helpful
Study: the response of the different healthcare members of the different hierarchies would be
analyzed. Moreover data should be also collected by observing the impact of the policies on the
workplace and reduction of the rates of pressure ulcers.
Act: if the results are positive, the policies and guidelines would be published and if changes are
required and loopholes are found, they would be modified once again.

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Evaluation plan:
An evaluation team needs to be formed. The team will be observing the data and results
of each of the planning and initiatives that had been taken through the PDSA cycle. In order to
evaluate the development of organizational climate, feedback sessions would be arranged. Here
the professionals will impart about how the organizational climate is changing or they are not
experiencing any changes in the rates of the pressure ulcer occurrence (Recio et al., 2016). The
other part is the score evaluation and questionnaire evaluation of the nurses who are attending
training sessions for the identification and reduction of pressure ulcer occurrences in the
admitted patients. This would help to know how the nurses are developing knowledge and skills
to ensure safe and quality care to patients (Webster et al., 2017). Surveys would be arranged for
developing knowledge about the impact of policies and guidelines for prevention of pressure
ulcers in patients. These would help in the effective evaluation of rates of pressure ulcers
decreasing in the organization.
Conclusion:
Pressure ulcer is one of the hospital associated complications that act as indicators of
compromised patient safety and poor quality care by the professionals. It has the ability to impact
the quality of life of patients enhancing their pain, suffering, stay at hospital and financial
outflow. It also can result in wastage of healthcare resources as it is preventable through effective
care. Developmental of organizational culture, training of the nurses and effective introduction of
policies and guidelines would be extremely helpful in preventing the occurrences of pressure
ulcers. The reduction of the rate of the pressure ulcers can signify development of skills and

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knowledge of the professionals, effective organizational culture of safety and proper following of
the policy and framework protocols for ensuring prevention of the pressure ulcers in hospitals.

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References:
Bharucha, J. B., Seaman, L., Powers, M., Kelly, E., Seaman, R., Forcier, L., ... & Nodiff, S.
(2018). A Prospective Randomized Clinical Trial of a Novel, Noninvasive Perfusion
Enhancement System for the Prevention of Hospital-Acquired Sacral Pressure
Injuries. Journal of Wound Ostomy & Continence Nursing, 45(4), 310-318. doi:
10.1097/WON.0000000000000450
Bredesen, I. M., Bjøro, K., Gunningberg, L., & Hofoss, D. (2015). The prevalence, prevention
and multilevel variance of pressure ulcers in Norwegian hospitals: a cross-sectional
study. International journal of nursing studies, 52(1), 149-156.
https://doi.org/10.1016/j.ijnurstu.2014.07.005
Chaboyer, W. P., Thalib, L., Harbeck, E. L., Coyer, F. M., Blot, S., Bull, C. F., ... & Lin, F. F.
(2018). Incidence and Prevalence of Pressure Injuries in Adult Intensive Care Patients: A
Systematic Review and Meta-Analysis. Critical care medicine, 46(11), e1074-e1081. doi:
10.1097/CCM.0000000000003366
Cox, J., & Roche, S. (2015). Vasopressors and development of pressure ulcers in adult critical
care patients. American Journal of Critical Care, 24(6), 501-510.
http://ajcc.aacnjournals.org/content/24/6/501.short
Cutting, K. F., & White, R. J. (2015). Deaths and pressure ulcers: should death certificate
reporting be mandatory?.
https://www.researchgate.net/profile/Keith_Cutting/publication/274192321_Cutting_and
_White_Deaths_and_pressure_ulcers_should_death_certificate_reporting_be_mandatory
_British_Journal_of_Nursing_2015_Tissue_Viability_Supplement_Vol_24_No_6/links/

13
INDICATORS OF PATIENT SAFETY AND SERVICE QUALITY
562e49de08ae518e3483654a/Cutting-and-White-Deaths-and-pressure-ulcers-should-
death-certificate-reporting-be-mandatory-British-Journal-of-Nursing-2015-Tissue-
Viability-Supplement-Vol-24-No-6.pdf
de Almeida Medeiros, A. B., Fernandes, M. I. D. C. D., de Sá Tinôco, J. D., Cossi, M. S., de
Oliveira Lopes, M. V., & de Carvalho Lira, A. L. B. (2018). Predictors of pressure ulcer
risk in adult intensive care patients: A retrospective case-control study. Intensive and
Critical Care Nursing, 45, 6-10. https://doi.org/10.1016/j.iccn.2017.09.007
Fabbruzzo-Cota, C., Frecea, M., Kozell, K., Pere, K., Thompson, T., Thomas, J. T., & Wong, A.
(2016). A Clinical Nurse Specialist–Led Interprofessional Quality Improvement Project
to Reduce Hospital-Acquired Pressure Ulcers. Clinical Nurse Specialist, 30(2), 110-116.
doi: 10.1097/NUR.0000000000000191
Goudie, A., Dynan, L., Brady, P. W., Fieldston, E., Brilli, R. J., & Walsh, K. E. (2015). Costs of
venous thromboembolism, catheter-associated urinary tract infection, and pressure
ulcer. Pediatrics, peds-2015.
http://pediatrics.aappublications.org/content/early/2015/08/05/peds.2015-1386
Griffiths, P., Ball, J., Drennan, J., Dall’Ora, C., Jones, J., Maruotti, A., ... & Simon, M. (2016).
Nurse staffing and patient outcomes: strengths and limitations of the evidence to inform
policy and practice. A review and discussion paper based on evidence reviewed for the
National Institute for Health and Care Excellence Safe Staffing guideline
development. International journal of nursing studies, 63, 213-225.
https://doi.org/10.1016/j.ijnurstu.2016.03.012

14
INDICATORS OF PATIENT SAFETY AND SERVICE QUALITY
Johnson, S. (2016). The Effectiveness of an Organizational Hospital-Acquired Pressure Ulcer
Prevention Workshop on Pressure Ulcer Prevalence Rates.
https://scholarworks.waldenu.edu/dissertations/2089/
Kronick, R., Arnold, S., & Brady, J. (2016). Improving safety for hospitalized patients: much
progress but many challenges remain. Jama, 316(5), 489-490.
doi:10.1001/jama.2016.7887
Lavallée, J. F., Gray, T. A., Dumville, J., & Cullum, N. (2018). Barriers and facilitators to
preventing pressure ulcers in nursing home residents: A qualitative analysis informed by
the Theoretical Domains Framework. International journal of nursing studies, 82, 79-89.
https://doi.org/10.1016/j.ijnurstu.2017.12.015
Linton, P., Kim, I., Ayello, E. A., Miller, S., & O’Neill, D. K. (2016). Prone airway management
in patients with pressure ulcers. J Anesth Pati Care, 1(2), 201.
https://pdfs.semanticscholar.org/a9d5/d4127c7062742612870a8c26ade69851e0c9.pdf
Moore, Z., Soriano, J. V., Pokorná, A., Schoonhoven, L., Vuagnat, H., Markova, A., &
Kristensen, J. (2017). The Joint EPUAP & EWMA Pressure Ulcer Prevention & Patient
Safety Advocacy Project. Wounds UK, 13(3). https://web.b.ebscohost.com/abstract?
direct=true&profile=ehost&scope=site&authtype=crawler&jrnl=17466814&AN=125493
607&h=b4wKMYx%2b
%2fMFTjRfKcUJvOOSpceAv22ZNn5CgjF63EMmIjqXLFwkN9Hjdfv96XDcUQROaW
vW2%2fEAftyGvC94NSQ%3d
%3d&crl=c&resultNs=AdminWebAuth&resultLocal=ErrCrlNotAuth&crlhashurl=login.a

15
INDICATORS OF PATIENT SAFETY AND SERVICE QUALITY
spx%3fdirect%3dtrue%26profile%3dehost%26scope%3dsite%26authtype%3dcrawler
%26jrnl%3d17466814%26AN%3d125493607
Palfreyman, S. J., & Stone, P. W. (2015). A systematic review of economic evaluations assessing
interventions aimed at preventing or treating pressure ulcers. Int J Nurs Stud, 52(3), 769-
88. https://doi.org/10.1016/j.ijnurstu.2014.06.004
Recio‐Saucedo, A., Dall'Ora, C., Maruotti, A., Ball, J., Briggs, J., Meredith, P., ... & Griffiths, P.
(2018). What impact does nursing care left undone have on patient outcomes? Review of
the literature. Journal of clinical nursing, 27(11-12), 2248-2259.
https://doi.org/10.1111/jocn.14058
Stalpers, D., de Brouwer, B. J., Kaljouw, M. J., & Schuurmans, M. J. (2015). Associations
between characteristics of the nurse work environment and five nurse-sensitive patient
outcomes in hospitals: a systematic review of literature. International Journal of Nursing
Studies, 52(4), 817-835. https://doi.org/10.1016/j.ijnurstu.2015.01.005
van Dishoeck, A. M., Looman, C. W., Steyerberg, E. W., Halfens, R. J., & Mackenbach, J. P.
(2016). Performance indicators; the association between the quality of preventive care
and the prevalence of hospital‐acquired skin lesions in adult hospital patients. Journal of
advanced nursing, 72(11), 2818-2830. https://doi.org/10.1111/jan.13044
Webster, J., Bucknall, T., Wallis, M., McInnes, E., Roberts, S., & Chaboyer, W. (2017). Does
participating in a clinical trial affect subsequent nursing management? Post-trial care for
participants recruited to the INTACT pressure ulcer prevention trial: A follow-up
study. International journal of nursing studies, 71, 34-38.
https://doi.org/10.1016/j.ijnurstu.2017.02.022

16
INDICATORS OF PATIENT SAFETY AND SERVICE QUALITY
Zubkoff, L., Neily, J., King, B. J., Dellefield, M. E., Krein, S., Young-Xu, Y., ... & Mills, P. D.
(2016). Virtual breakthrough series, Part 1: preventing catheter-associated urinary tract
infection and hospital-acquired pressure ulcers in the Veterans Health
Administration. The Joint Commission Journal on Quality and Patient Safety, 42(11),
485-AP2. https://doi.org/10.1016/S1553-7250(16)42091-X