CILIPS Chartered Institute of Library and Information Professionals in Scotland
Navigation Close

Case Study – Unavoidable pressure damage: criteria to support outcome determination

Case study provided by Kathryn Brechin, Head of Nursing (Acute Services), NHS Fife

Project outline: 

Across all areas of healthcare we are challenged with reducing avoidable harms to patients including harm associated with pressure damage. Within the organisation we report all suspected pressure damage Grade 2 and above, and all suspected damage Grade 3 and above is reported as “major harm”. The major harm reports are then subject to a Rapid Events Investigation and review at a cluster meeting involving the input and expertise of specialist tissue viability practitioners, podiatry, and other ward teams, with the meeting chaired by a senior nurse. The aim of this review is to provide scrutiny to the case review process, identify areas of individual and corporate learning, and recognise areas of good practice. On rare occasions there were cases presented whereby the care given to the patient was recognised to be of a high standard but despite the care a patient received they developed pressure damage. In these cases an identified causative or contributory factor was always recognised, for example, harm occurred due to an overriding life critical event or treatment that either increased risk significantly or restricted/prevented appropriate pressure relieving measures to be put in place. The published evidence provided by the library service allowed the clinical service to produce a detailed guideline providing criteria built into a robust governance framework of transparent review and scrutiny to support a consistent approach to an investigation outcome of unavoidable harm. By recognising that there are a small number of exceptional circumstances where pressure damage is unavoidable, it enables positive feedback to clinical teams recognising the high standards of care delivered, and ensures that the focus of improvement work is reasonably focused on areas where different measures would affect a patient’s outcome and mitigate against harm.

Quote from Senior Charge Nurse, ICU:

“Pressure damage in ICU being reviewed at Tissue Viability cluster review with a sound evidence base behind the tools used to assess unavoidability of harm has been invaluable. This has the outcome of reassuring me that the care delivered to patients in ICU is appropriate with respect to much of the damage that occurs. This approach ensures that changes in delivery of clinical care are focussed on areas where any change will benefit patient care.” Feedback from Tissue Viability Nurse Specialist – “The literature review and library support informed the development of the avoidable/unavoidable criteria. This has raised awareness with both specialists and ward staff that there should be a differentiation between avoidable and unavoidable damage. This has ensured a high level of scrutiny during pressure ulcer investigation from the stage of SBAR and REI/Cluster.”

Quote from Head of Nursing:

“By reviewing the literature provided by the library service I was able to assure myself and the organisation that the approach to assessing and determining an outcome following a critical review of patient harm is consistent, using criteria reflecting the evidence base.”

Further information: 

The use of an evidence base to underpin the standards we measure our practice against allows an informed decision about the local implications and applications of practice, and ensures that the delivery of person-centred high quality care is recognised and celebrated, and that improvement work focuses on areas that can be changed or influenced and that benefit patients in our care.