ArticleBMJ open2014
Why do patients develop severe pressure ulcers? A retrospective case study.
Article in BMJ open, 2014. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 9 papers, 1 of them a synthesis that pooled it.
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Who cites it
9 citing papers in PubMed, 1 synthesis or guideline pooled it.
- Measuring the quality of pressure ulcer prevention: A systematic mapping review of quality indicators.International wound journal · 2018Pooled it
- Bridging the Gap Between Awareness and Behaviour in Pressure Injury Prevention: A Cross-Sectional Survey of Self-Management in People With Spinal Cord Injury.International wound journal · 2026Article
- Pressure injury prevention practices among medical surgical nurses in a tertiary hospital: An observational and chart audit study.International wound journal · 2022Observational
- Improving the quality of pressure ulcer management in a skilled nursing facility.International wound journal · 2019Article
- An interprofessional approach to pressure ulcer prevention: a knowledge and attitudes evaluation.Journal of multidisciplinary healthcare · 2019Article
- Article
- Clinical evaluation of a new pressure ulcer risk assessment instrument, the Pressure Ulcer Risk Primary or Secondary Evaluation Tool (PURPOSE T).Journal of advanced nursing · 2018Article
- Grafting with Cryopreserved Amniotic Membrane versus Conservative Wound Care in Treatment of Pressure Ulcers: A Randomized Clinical Trial.Bulletin of emergency and trauma · 2017Article
- Developing a pressure ulcer risk factor minimum data set and risk assessment framework.Journal of advanced nursing · 2014Article
Corrections and comments
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Authors and funding
10 authors.
Funding
Abstract
objectivesThis study focuses on the ways in which the organisational context can influence the development of severe pressure ulcers. Severe pressure ulcers are important indicators of failures in the organisation and delivery of treatment and care. We have a good understanding of patients' risk factors, but a poor understanding of the role played by the organisational context in their development.
settingThe study was undertaken in six sites in Yorkshire, England. The settings were sampled in order to maximise diversity, and included patients' own homes, acute hospital medical and surgical wards, a community hospital and a nursing home during a period of respite care.
participantsData were collected about eight individuals who developed severe pressure ulcers, using a retrospective case study design. The data sources included interviews with individuals with severe pressure ulcers, and with staff who had treated and cared for them, and clinical notes.
results4 accounts indicated that specific actions by clinicians contributed to the development of severe pressure ulcers. Seven of the 8 accounts indicated that they developed in organisational contexts where (1) clinicians failed to listen and respond to the patients' or carers' observations about their risks or the quality of their treatment and care, (2) clinicians failed to recognise and respond to clear signs that a patient had a pressure ulcer or was at risk of developing one and (3) services were not effectively coordinated.
conclusionsPatient accounts could only be partially explained in terms of specific events or sequences of events. The findings support the conclusion that there was general acceptance of suboptimal clinical practices in 7 of the 8 contexts where patients developed severe pressure ulcers.
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