Using quality improvement science to reduce the risk of pressure ulcer occurrence - a case study in NHS Tayside
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Mackie, S., Baldie, D., McKenna, E. & O''Connor, P. (2014) Using quality improvement science to reduce the risk of pressure ulcer occurrence - a case study in NHS Tayside, Clinical Risk, vol. 20, , pp. 134-143,
Pressure ulcer prevention is core to nursing practice and as such is often overlooked as a safety risk. A multifaceted quality improvement initiative guided by both Felgen's Model and the Model for Improvement delivered implemented in a systematic way led to significant improvements in the prevalence and incidence of pressure ulcers. Prevalence of all ulcers was reduced from 21% to 7% and to 3.1% when grade 1 ulcers are removed from analysis. Incidence (i.e. ulcers acquired in hospital) was reduced from 6.6% to 2.4% and 1.4% when grade 1 ulcers are removed from the analysis. Furthermore, improvements have been sustained for more than 2 years. This paper presents a case study of framework for change developed across a healthcare region NHS Tayside in Scotland.