Reducing avoidable harm caused by pressure ulcers.

This article reports on the successful work undertaken within one NHS trust to reduce the incidence of pressure ulcers. The tissue viability nursing team at Medway NHS Foundation Trust devised, implemented and evaluated a strategy to reduce the incidence of pressure ulcers. This involved devising a comprehensive database, intensive monitoring using root cause analysis, writing action plans using high-impact actions (HIAs) and innovative thinking to address and reduce the incidence of pressure ulcers and staff training in the use of the SKIN acronym. This work identified pressure ulcers on the ears of patients receiving oxygen therapy as a particular problem. An evidence-based and multiprofessional strategy was devised to deal with this particular problem, which resulted in no further incidence of pressure ulcers on the ears of patients receiving oxygen therapy. The entire pressure ulcer reduction strategy was positively evaluated and proved to be sustainable.