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Pressure Ulcers or Bedsores in Hospitals and Nursing Homes Should Never Happen


Posted by Brendan Faulkner of D'Amico & Pettinicchi, LLC on Sep 15, 2012 in Medical Malpractice

Certain types of medical events should never happen.  These include pressure ulcers or bedsores in the acute care setting.  (Pressure ulcers are also preventable in nursing homes.)

Pressure ulcers or bedsores are the 4th most common preventable medical error in the United States (3 million patients are treated annually at an average cost of $43,000 per hospital stay.) [Pressure Ulcer Facts (Dorner, B., Posthauer, M.E., Thomas, D. 2009)] 

Never events are a series of medical errors that are defined as "clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility." Stage 3 and 4 pressure ulcers are listed as a never event by the Centers for Medicare and Medicaid Services.  In 2007, CMS (the Centers for Medicare and Medicaid Services) announced that Medicare would no longer pay for additional costs associated with many preventable errors, including those considered Never Events. Many states and private insurers have adopted similar policies. Accordingly, since Never Events are devastating and preventable, health care organizations are under intense pressure to eliminate them completely. 

The National Quality Forum (NQF) has endorsed a quality measurement framework for preventing and managing pressure ulcers across clinical care settings.  NQF is a voluntary consensus standards-setting organization.

By following some simple steps that are based on best practice, the health professional can team up with the patient and other caregivers to create an environment where pressure ulcers are reduced and even eliminated. Pressure ulcers may be prevented by implementing the following care measures:

  • Provide good skin care
  • Wash skin with warm water using mild soap
  • Protect the skin from sweat and urine
  • Keep clothes, skin, and bed sheets clean and dry
  • Apply moisturizing cream on skin every day
  • Frequently turn and re-position the patient
  • Encourage mobility
  • Assist with toileting needs
  • Encourage and provide a nutritious diet and ample fluids
  • Providing pressure reducing cushions, mattresses, beds, and elbow pads
  • Using a lifting device to move or lift patient

Pressure ulcers are much easier to prevent than to treat.  Once they have formed, they can lead to intense pain and even death.  It is therefore crucial that hospitals, rehabilitation facilities, and nursing homes prevent pressure ulcers before they begin to form.

D'Amico & Pettinicchi has extensive experience representing patients and nursing home residents who have unnecessarily suffered as a result of bedsores and other preventable medical errors.