Implementing an Electronic Root Cause Analysis Reporting System to Decrease Hospital-Acquired Pressure Injuries

Hospital-acquired pressure injuries (HAPIs) continue to increase in comparison to other hospital-acquired conditions, despite advancements in prevention and wound care practices. In 2017, an interprofessional skin team (IST) was formed at an academic medical center to improve patient care and reduce HAPIs. Intentional wound, ostomy, continence (WOC) nurse rounding coupled with IST efforts steadily decreased HAPIs in the organization by 39%. In an effort to continue to improve care, a root cause analysis (RCA) of HAPIs was initiated in two intensive care units (ICUs) in October 2019. Using the Plan-Do-Study-Act model, two WOC nurses and a nursing professional development specialist from the IST developed the HAPIs RCA process. Rapid cycle process improvement demonstrated the need to transition from a paper form to an electronic process to increase accessibility for all nursing units and patients to benefit. In May 2020, an electronic reporting system for RCAs for HAPIs began. After implementation, there has been a 53.5% reduction in HAPIs over 2 years. The standardized, electronic RCA process has resulted in improvement, dissemination of best practices, and fostering nonpunitive accountability for each unit's HAPIs.