The Essential Guide to Reporting Pressure Ulcer Incidents

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A Significant Health Issue

Pressure ulcers, also known as pressure injuries or bedsores, are a significant health issue. Pressure ulcers develop when there is constant pressure on a particular area of the skin, often from lying in the same position for too long without relief. The harm can vary in severity, from mild reddening of the skin to deep wounds that extend into the muscle and bone. 


Pressure ulcers are commonly seen in high-risk individuals, such as the elderly, the critically ill and those who are bedridden or wheelchair bound. If left untreated, pressure ulcers can lead to serious complications, including risk of infection, pain and discomfort, decreased mobility, and even death in severe cases. Pressure ulcers also contribute to significant healthcare costs due to prolonged hospital stays and additional treatments. Preventing pressure injuries has been a constant challenge in hospitals, nursing homes and elderly care facilities.


This blog looks at several stages of pressure ulcers, prevention strategies and reporting of pressure ulcer incidents so that appropriate preventive actions can be taken.

Table of Contents

Pressure Ulcer Stages

Understanding the different stages of pressure ulcers is fundamental for effective prevention, early detection, appropriate treatment, and management of these wounds, ultimately improving outcomes for affected individuals and reducing the burden of pressure injuries on healthcare systems.


Pressure ulcers are staged to indicate the extent of tissue damage. There is also an unstageable category for ulcers where the full extent of tissue damage cannot be determined due to necrosis or eschar. The severity of the ulcer directs the appropriate treatment, which may involve relieving pressure on the affected area, keeping the wound clean and moist, managing pain, and addressing any underlying health issues contributing to ulcer formation. 


The 4 stages of pressure ulcers are as follow:


  • Stage 1: Non-blanch able erythematic – have not yet broken through the skin.
  • Stage 2: Partial thickness – have a break in the top two layers of skin.
  • Stage 3: Full thickness skin loss – affect the top two layers of skin, as well as fatty tissue.
  • Stage 4: Full thickness tissue loss – deep wounds that may impact muscle, tendons, ligaments, and bone.
  • Suspected Deep Pressure Injury.
  • Unstageable Sores.


Healthcare professionals, particularly nurses and wound care specialists, play a significant role in the prevention, assessment, and treatment of pressure ulcers. 


They may employ various techniques to manage pressure ulcers effectively and promote healing. Prevention is crucial in managing pressure ulcers, especially in individuals who are bedridden or have limited mobility.

Pressure Ulcer Prevention Strategies

The prevention of pressure ulcers is one of the key patient safety focuses in healthcare. This task is not solely the responsibility of nursing but requires multi-disciplinary collaborations, clear policies and protocols, and a culture that promotes safety.


Risk assessment is at the center of good clinical practice. It is an essential first step to identify individuals who are more likely to develop pressure ulcers. Other interventions include reducing pressure and friction on the skin through repositioning and encouraging regular movement, as well as maintaining good skin health. Educating caregivers and patients about the importance of pressure ulcer prevention is also an effective strategy.


Based on the National Pressure Injury Advisory Panel’s “Pressure Injury Prevention Points”, we have listed below 5 broad strategies and selected prevention points:


  1. Risk Assessment
    Conducting a risk assessment to identify patients who are more likely to develop pressure ulcers should be the starting point. The earlier a risk is identified, the more quickly it can be addressed.
    • Use a structured risk assessment tool, such as the Braden Scale, to identify individuals at risk for pressure injury as soon as possible (within 8 hours after admission)
    • Refine the assessment by identifying additional risk factors such as the history of pressure ulcers and existing pressure injuries.
    • Repeat the assessment at regular intervals and with any change in condition.
    • Develop a care plan based on the areas of risk.


  1. Skin Care
    Monitoring skin condition and maintaining skin hygiene is important for preventing pressure sores and identifying Stage 1 sores early so they can be treated before they worsen.
    • Inspect the skin upon admission and at least daily for signs of pressure injury.
    • Assess pressure points and the skin beneath medical devices.
    • Cleanse the skin promptly after episodes of incontinence. Use skin cleansers and skin moisturizers daily on dry skin.
    • Avoid positioning an individual on an area of pressure injury.


  2. Nutrition
    Consider hospitalized individuals to be at risk for undernutrition and malnutrition from their illness.
    • Use a valid tool to determine the risk of malnutrition.
    • Refer all individuals at risk to a registered dietitian/nutritionist.
    • Encourage at-risk individuals to have adequate fluids and a balanced diet.
    • Provide nutritional supplements if required.


  3. Repositioning and Mobilization
    Prevent prolonged pressure on specific parts of the body. Immobility is a main factor in causing pressure injuries.
    • Turn and reposition all at-risk individuals, if not contraindicated due to medical conditions.
    • Choose a frequency for turning and repositioning the patient.
    • Use appropriate padding and positioning devices.
    • Consider the level of immobility, body size, and weight when choosing a support surface.


  4. Training and Patient Engagement
    Educate and train caregivers about the importance of pressure ulcer prevention, including proper positioning techniques, skin care practices, and the use of assistive devices.
    • Educate the individual and family about the risk of pressure injury.
    • Engage individuals and families in risk-reduction interventions.
    • Report and monitor pressure ulcer incidents and take preventive actions.


Preventive strategies, early detection, and appropriate management are crucial in reducing the incidence and severity of pressure ulcers and improving patient outcomes.

Reporting Pressure Ulcer Incidents

Pressure ulcer incident reporting is a crucial aspect of patient safety and quality management, particularly in settings where patients may be at risk of developing pressure ulcers, such as hospitals, nursing homes, and long-term care facilities. 


Healthcare facilities typically have protocols for incident reporting, which may involve paper-based incident forms or online systems. When a pressure ulcer is discovered, it should be reported according to these protocols. The report should include details of the ulcer, circumstances surrounding its development, and any actions taken in response. Stage 3 and 4 pressure ulcers are patient safety events that could be a sentinel event.


Incident reporting data for pressure ulcers can provide actionable insights for initiating quality improvement plans. By analysing trends in pressure ulcer incidents, healthcare providers can identify opportunities to enhance preventive measures, staff education, and overall patient care practices.

Relevant Incident Details

Here is an outline of the relevant questions when reporting pressure ulcer incidents and why this information is important.

1. Brief description of the incident occurredIncluding the most advanced stage of the pressure ulcer and any immediate action taken to make the situation safe.
2. Indicate the location of the ulcerTo aid in the statistic and further analysis. Common sites include the sacrum, heels, hips, ankles, elbows, and shoulder blades.
3. Was there any documentation done about the patient skin inspection upon admission to this facility?This is to ensure patient skin has been assessed upon arrival to the facility and that appropriate steps have been taken according to the policy/practice to address the issue of pressure sore. Also, this helps to identify if the ulcer existed earlier on the patient. If there is no documentation, further step is to understand why it was not done.
4. Was there risk assessment conducted?i. Risk Assessment Tools. Pressure ulcer risk assessment tools are used to identify patients who are at risk of developing pressure ulcers. These tools help to assess various factors that contribute to pressure ulcer development and include a scoring system to predict pressure ulcer risk. The commonly used pressure ulcer risk assessment tools are the Braden Scale, the Norton Scale, and the Waterlow Scale. Braden Q Scale is used for children.

ii. Further Clinical Assessment. However, do not rely on the risk scores alone. Even patients with a low-risk score may need intervention. Instead, care givers should conduct further clinical assessments including looking at the patient’s pressure ulcer history, assessing co-morbidities and medications, and looking and touching the skin. Skin temperature may predict pressure ulcer risk.

Some healthcare settings may not be using any risk assessment tools. As such, they may use the traditional method to assess patient’s skin condition.
5. As a result of the assessment, was the patient documented to be at increased risk of pressure ulcer?If yes, appropriate measure should be included in patient’s care plan. Absent of this step could have been contribute to increased factor of the ulcer development.
6. What was the preventive intervention implemented?By indicating the intervention, the healthcare personnel can brainstorm if there is any other intervention required apart from the ‘usual’ steps taken. Else, they may need to relook into the preventive actions.
7. During the patient’s stay at this facility, did the patient develop a secondary morbidity (e.g., osteomyelitis, sepsis, tunnelling, or fissure)? Was the secondary morbidity attributed to the presence of the pressure ulcer?The reason of such probing question helps the organization to address if there is any alarming situation happening so that it can be resolved immediately and avoid any potential legal issues.

Implementing Plan of Care

After reporting the incident, appropriate measures should be taken to address the pressure ulcer and prevent further complications. This may include implementing a treatment plan, such as wound care interventions, repositioning schedules, pressure-relieving devices, and nutritional support. Additionally, the patient’s condition should be closely monitored to track the ulcer’s progress and ensure that it heals effectively.


Reporting pressure ulcer incidents is essential for maintaining a proactive approach to pressure ulcer management. Timely and comprehensive reporting of pressure ulcer incidents allows healthcare facilities to assess and manage the associated risks. Identifying factors contributing to pressure ulcer development helps in implementing preventive measures and minimizing the likelihood of future incidents, thereby improving care quality, and reducing potential liability and financial costs.

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QUASR is a cloud-based healthcare incident reporting system. It offers functionalities that encourage Patient Identification Error reporting, facilitate collaboration, enable analysis, and track actions.

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