National Quality Forum and “Never Events”: Addressing Pressure Ulcers

Introduction

The National Quality Forum (NQF) is a not-for-profit organization in the United States dedicated to improving healthcare quality and patient safety. One of the critical areas of focus for NQF is the identification and prevention of “never events,” which are serious, preventable medical errors that should never occur in healthcare settings. Among these never events are pressure ulcers, also known as bedsores, which can have severe consequences for patients including death. In this article, we will delve into the role of the National Quality Forum in addressing never events, with a particular focus on the prevention and management of pressure ulcers.

The National Quality Forum and Never Events

The National Quality Forum was established in 1999 with a mission to improve healthcare quality and patient safety through collaboration and the endorsement of evidence-based quality measures and practices. One of its significant contributions to healthcare quality improvement has been the identification and classification of never events.

Never events are medical errors or injuries that are entirely preventable and should never occur under any circumstances. They are grouped into several categories, including surgical, product or device, patient protection, care management, and environmental events. Pressure ulcers fall under the “care management” category.

Pressure Ulcers as Never Events

Pressure ulcers, commonly known as bedsores, are localized injuries to the skin and underlying tissue, typically occurring over bony prominences when constant pressure or friction is applied. While they can develop in various healthcare settings, including hospitals, nursing homes, and long-term care facilities, the NQF specifically addresses pressure ulcers as never events in hospitals. Common sense tells us that the same principles apply in the nursing home and assisted living facility context. The designation of pressure ulcers or bedsores as never events underscores the preventable nature of pressure ulcers and the responsibility of healthcare providers to ensure patient safety.

Prevention and Management of Pressure Ulcers

Preventing pressure ulcers in hospital and nursing home settings is essential not only to comply with NQF guidelines but also to provide the highest standard of patient care. Several strategies can help prevent and manage pressure ulcers:

Risk Assessment: Conducting a thorough assessment of each patient’s risk factors for pressure ulcers is the first step. Factors such as immobility, incontinence, malnutrition must be taken into account.

Repositioning and Mobility: Frequent repositioning of bedridden or immobile patients is crucial to relieve pressure on vulnerable areas of the body. Proper lifting and transferring techniques are also essential. Most health care facilities use a standard protocol that requires repositioning a resident/patient every two hours. Generally, residents and patients must be repositioned every two hours or as needed to prevent bedsores, even if the resident or patient is on a special mattress.

Pressure-Relieving Devices: Specialized pressure-relieving mattresses and cushions can distribute pressure more evenly, reducing the risk of pressure ulcers.

Skin Care: Maintaining proper skin hygiene and moisture control is vital. Patients should be kept clean and dry, and moisturizing creams can be used to prevent dryness and friction.

Nutrition and Hydration: Adequate nutrition and hydration support tissue repair and skin integrity. Malnourished patients are more susceptible to pressure ulcers.

Education and Training: Healthcare staff should receive training in pressure ulcer prevention and management. Patients and their families should also be educated on the importance of skin care and pressure relief.

Monitoring and Documentation: Regular skin assessments and documentation of any changes are essential for early detection and intervention.

Consequences of Pressure Ulcers

Pressure ulcers can lead to severe complications, including infection, cellulitis, sepsis, and, in extreme cases, tissue necrosis and death. They can significantly prolong hospital stays, increase healthcare costs, and negatively impact a patient’s overall quality of life. Furthermore, pressure ulcers can lead to legal repercussions for healthcare facilities, emphasizing the importance of proper prevention and management.

Conclusion

The National Quality Forum plays a crucial role in improving healthcare quality and patient safety by identifying and addressing never events, including pressure ulcers or bedsores. Pressure ulcers, when they occur in hospital settings, are considered preventable medical errors that should never happen. Preventing and managing pressure ulcers requires a comprehensive approach, including risk assessment, repositioning, pressure-relieving devices, and proper nutrition. By adhering to NQF guidelines and best practices, healthcare providers can ensure that pressure ulcers are truly “never events” and provide the highest standard of care to their patients. Attorney Thomas W. Pleasant and Pleasant Law, PLLC have been handling bedsore cases against nursing homes and other healthcare facilities for over 15 years. Contact Pleasant Law, PLLC if you believe nursing home negligence has caused injury or death to someone you love.