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Pressure injury reporting

Pressure injury reporting

To ensure consistent and accurate reporting of pressure injuries in order to improve the prevention and management of pressure injury for our patients.


  • Reducing harm from pressure injuries is one of our patient safety improvement priorities at Waitemata DHB
  • Consistent and accurate reporting of pressure injury data is needed to inform improvement initiatives and track progress over time however, recent audits suggest that the quality of the data has been variable because of:
    • inconsistent and inaccurate data being recorded
    • multiple data sources (eg RiskMonitorPro (incident reporting system), Clinical coding, clinical audits) each providing different pressure injury rates so the true incidence of harm was not clear

What did we do?

In order to improve the consistency and accuracy of pressure injury reporting and obtain meaningful data to inform improvement and track progress, we focused on enhancing four key areas:

1.  Pressure injury reporting governance and resources

  • We introduced a Pressure Injury Management Group to promote, analyse and monitor pressure injury management
  • Pressure injury champions on each ward helped support staff education, consistent pressure injury auditing and pressure injury management
  • We updated our pressure injury policy, developed educational resources and targeted teaching sessions to provide clear guidance on reporting requirements

Pressure injury management poster

2.  Standardisation and improvements for reporting systems

  • We standardised the language and terminology used to describe pressure injuries across different reporting systems
  • We improved data collection and reporting systems so meaningful information could be obtained in a timely manner

3.  Improving the identification of pressure injuries during the clinical coding process

  • We introduced a “pressure injury sticker” to be placed in the patient’s clinical records to promote accurate reporting and easy identification of pressure injuries
  • We conducted regular audits to determine if the “pressure injury stickers” were used and whether documentation was complete and appropriate

Pressure injury sticker [view larger image]

4.  Improving the quality of pressure injury audits

  • We updated the prevalence audit to include review of documentation, reporting and sticker use

Did we make a difference?

There have been significant and sustained improvements in pressure injury reporting since the implemented changes in June 2014.

1.  Increase in the number of Hospital Acquired Pressure Injuries reported

The number of hospital acquired pressure injuries voluntarily reported in Risk MonitorPro has steadily increased and this reflects improved reporting by staff rather than increased incidences of harm.

2.  Better and more accurate identification of Hospital Acquired pressure injuries by multiple systems (Risk MonitorPro, Coding and Prevalence audit)

The use of the "pressure injury stickers" has meant that injuries identified in Risk MonitorPro reports are now more likely to also be identified via clinical coding systems and auditing and this helps us better identify all pressure injuries that occur

Where to from here?

  • The Pressure Injury Management Group and pressure injury champions will ensure that there are processes for ongoing review of pressure injury reporting and management
  • Once we have a better understanding of the incidence of harm from accurate data we will be able to identify areas for improvement to reduce pressure injuries

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