Pressure Injury Research Paper 2022

Running head: PRESSURE INJURY 1
Pressure Injury
Name
Institution

PRESSURE INJURY 2
Table of Contents
Introduction................................................................................................................ 3
Background................................................................................................................ 4
Baseline Measurement............................................................................................... 5
Design........................................................................................................................ 6
Process Map............................................................................................................... 8
Strategy...................................................................................................................... 8
PDSA Cycle 1........................................................................................................... 9
PDSA Cycle 2........................................................................................................... 9
PDSA Cycle 3........................................................................................................... 9
PDSA Cycle 4......................................................................................................... 10
Results...................................................................................................................... 10
Strengths and Limitations........................................................................................ 10
Ethical Approval....................................................................................................... 11
Conclusion................................................................................................................ 11
Reference................................................................................................................. 12

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Introduction
Patient safety may be described as the act of preventing adverse effects and errors from affecting
patients in a healthcare facility (Vincent, 2011). Hospitals and other healthcare organizations
ensure patient safety by protecting patients from injuries, errors, infections, and accidents during
the delivery of care within the hospitals (Miake-Lye, Hempel, Ganz & Shekelle, 2013). It is
worth noting that not all healthcare facilities are efficient and competent in ensuring the safety of
their patients and this is a serious problem (Jha, Prasopa-Plaizier, Larizgoitia & Bates, 2010).
Reports indicate that approximately 440, 000 patients succumb to errors in hospitals that can
easily be prevented ("What is Patient Safety?", 2019). Hospitals are therefore required to
implement the NSQHS Standards to ensure that the safety of their patients within the hospitals is
guaranteed.
One of the challenges that hospitals face which jeopardize the safety of their patients is pressure
injuries. Pressure injuries occur when forces are applied to the skin surface forcing the skin to
lose its integrity (Miles, Fulbrook, Nowicki & Franks, 2013). Other potential causes of pressure
injuries may include friction, poor flow of blood, tissue ischemia, and shear. This injury can
damage the skin, muscles, bone, skin, subcutaneous fat, and fascia thus affecting the quality of
health outcomes and increasing the length of hospital stay which also increases the cost of
healthcare (Alderden, Rondinelli, Pepper, Cummins & Whitney, 2017). It is important to note
that pressure injuries are more frequent among elderly patients because their skin is fragile
(Theisen, Drabik & Stock, 2012).
Individuals and organizations in charge of healthcare must aim to implement the necessary
nursing codes of ethics, standards of practice, and NSQHS Standards to ensure that patients are
safe and the quality of health outcomes is improved (ACSQHC, 2012). Implementation of these

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standards will help in reducing medication errors and in-patient injuries at Singapore General
Hospital. Nurses at Singapore General Hospital are being trained to know the best ways of
managing wounds and preventing pressure injuries during hospital stays. ‘
This paper aims to perform a clinical audit and talk about pressure injuries and their effects in
Australia and Singapore and the importance of training nurses to handle pressure injuries. This
paper will further talk about the level of nurse’s knowledge regarding pressure injuries and the
nurses’ adherence to the prevention protocols at Singapore General Hospital because most
injuries are experienced when patients are admitted to the hospital.
Background
For a very long time now, pressure injuries have been a serious problem in healthcare and their
prevention is a global problem (Razmus & Bergquist-Beringer, 2017). The clinical audit done by
this paper aims to assist nurses in acquiring the knowledge required to avoid and manage
pressure injuries. The clinical audit is vital to nurses because it will improve their comprehension
of the primary causes of pressure injuries and design clinical and nursing interventions to avoid
and handle pressure injuries and help patients experiencing the problem recover adequately.
The global problem of pressure injuries is a serious one that affects the safety of very many
patients. According to Jaul & Calderon‐Margalit (2015), more than 23% of patients at risk of
suffering the effects of pressure injuries do not get the required prevention strategies thus putting
their safety in jeopardy. One of the most important interventions that have been ignored for a
while now is the use of mattresses that relieve pressure thus avoiding unnecessary exertion of
force on any part of a patient’s body. Additionally, around 20%-58% of patients at risk of
pressure injuries are rarely repositioned when they lie on the bed (Spruce, 2018).