Avoiding Pressure Injury in the Operating Room with Root Cause Analysis & Action

Background: Pressure ulcer/injuries have always been a concern in healthcare, but have become a greater priority since the Centers for Medicare & Medicaid services introduced prospective bundled payment programs for surgical episodes of care which requires elimination of hospital acquired conditions (HACs) to achieve maximum reimbursement. The surgical population is aging and becoming more obese, increasing risk. The incidence of perioperative pressure injuries (PPI) over the past 5 years has NOT decreased, but increased. According to a 2014 publication from the National Pressure Ulcer Advisory Panel, the incident rate for pressure injury attributed to the operating room ranges from 5% to 53.4%. 

Purpose: High-reliability health care organizations (HCOs) create a safety culture where potential problems are anticipated, detected early, and timely response and action eliminate patient harm. Successful PPI prevention in vulnerable surgical patients includes: risk assessment, standardization of equipment and devices, and implementation of bundles utilizing AORN guidelines. Ongoing real-time Root Cause Analysis (RCA) in conjunction with a PPI gap assessment and incident reports are used to create a (SWOT) analysis i.e. strengths, weaknesses, opportunities, and threats. 

Methods: Using the Root Cause Analysis and Action (RCA2) model we advance lessons learned by investigating system failures. The interprofessional team of PeriAnesthesia nurses, perioperative nurses, anesthesia providers, wound, ostomy and continence nurses (WOCN), and surgeons must collaborate to identify gaps in knowledge, skills, and attitudes. The goal of process improvement is to integrate innovative practices, clear communication, and seamless teamwork into daily routines.  By addressing gaps in the current state with the evidence an ongoing action plan is created to provide continuous improvement. 

Conclusions: Achieving high-reliability and zero errors will require active engagement of leadership and support for the investigation and improvement process. By utilizing tools such as RCA2 model one facility reported zero PPI for 4 years.