Date of Graduation

Fall 12-12-2020

Document Type


Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Catherine Coleman

Second Advisor

Margaret Levine


Abstract PROBLEM: Currently healthcare acquired pressure injuries (HAPIs) in the United States result in significant and unnecessary costs along with lost revenue for healthcare facilities. These costs are estimated to be between 9.1 and 11.6 billion dollars annually. Pressure Injuries (PIs) are directly associated with decreases in patient outcomes and are deemed preventable incidents. HAPI prevention can mitigate this clinical and financial problem for patients and organizations. CONTEXT: Unnecessary patient harm related to four HAPI occurrences in the last quarter on the 2B Medical Surgical Telemetry Unit in an integrated managed care delivery system continue to be of concern. Adherence to current PI prevention methods is not adequate, and is demonstrated in electronic health record (EHR) audits. The improvement project described in this paper will address knowledge gaps regarding PI interventions, and establish a standardized HAPI prevention bundle. INTERVENTIONS: The project intervention involves implementation of a standardized skin safety bundle on an attachable laminated checklist to increase adherence to best practice guidelines associated with HAPI reduction and documentation. MEASURES: An outcome measure, three process measures, and one balancing measure were addressed in this project. The integrated managed care delivery system regional benchmark for HAPI’s is zero. The aim of this project is to reduce HAPIs down to one occurrence within a quarter and optimistically maintain the metric of zero in the future. RESULTS: Unfortunately, due to competing priorities related to the Coronavirus Pandemic this improvement project was only allocated time for a two week pilot study. During the pilot of the standardized skin safety bundle zero HAPIs were reported. CONCLUSION: A standardized HAPI prevention bundle checklist reduces HAPI incidents and preventable patient harm. Additional tests of change and improvement research for large REDUCING HOSPITAL ACQUIRED PRESSURE INJURIES 4 scale implementation and spread of the recommended skin safety bundle along with related documentation is encouraged. Keywords: HAPI, prevention, bundle, harm, cost, documentation