Date of Graduation

Winter 12-15-2023

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Kaiser cohort MSN capstone


Problem: A medical center in the Diablo Service Area had one of the highest rates in hospital-acquired pressure injury (HAPI), benchmarking with other facilities, with the project unit one of the top offenders. The patients and the medical center both suffered from the harm. Barriers to HAPI prevention included lack of patient turnings, skin assessment, and early standard wound care treatment.

Context: This project focused on the primary care team standardizing early wound care treatment to avoid wound progression.

Interventions: Interventions included re-educating the primary care team on early basic wound care using a standard wound care guideline created by a multidisciplinary team.

Measures: The outcome measure of the project was the monthly HAPI incidence on the unit. The process measures included wounds treated by the primary care team appropriately and nursing knowledge on basic wound care. The balancing measure included wounds treated by the primary care team inappropriately.

Result: The outcome measure was met in both May and June, with zero HAPI incidence. The process measure of wound treatment was not met in May (5%), but it was met in June (26%). Nursing knowledge on basic wound care increased from 70% to 90% (post project). The balancing measure remained at 0% throughout the 2 months.

Conclusions: HAPI prevention should continue to be a focus in the medical center. Patient harm was reduced, hospital’s financial burden was lessened, and the frontline staff were inspired due to ownership of the project. Further efforts will be made to spread the performance improvement project to other units to align with the medical center’s Magnet journey.

Included in

Nursing Commons