Using quality improvement science to reduce the risk of pressure ulcer occurrence – a case study in NHS Tayside

Susan Mackie (Lead / Corresponding author), Deborah Baldie, Eileen McKenna, Pat O'Connor

    Research output: Contribution to journalArticle


    Pressure ulcer prevention is core to nursing practice and as such is often overlooked as a safety risk. A multifaceted quality improvement initiative guided by both Felgen’s Model and the Model for Improvement delivered implemented in a systematic way led to significant improvements in the prevalence and incidence of pressure ulcers. Prevalence of all ulcers was reduced from 21% to 7% and to 3.1% when grade 1 ulcers are removed from analysis. Incidence (i.e. ulcers acquired in hospital) was reduced from 6.6% to 2.4% and 1.4% when grade 1 ulcers are removed from the analysis. Furthermore, improvements have been sustained for more than 2 years. This paper presents a case study of framework for change developed across a healthcare region NHS Tayside in Scotland.

    Original languageEnglish
    Pages (from-to)134-143
    Number of pages10
    JournalClinical Risk
    Issue number6
    Publication statusPublished - Nov 2014



    • Change models
    • Communicating risk
    • Improvement methods
    • Pressure ulcer
    • Risk management
    • Safe practice

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