Date of Graduation

Summer 8-9-2023

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Kaiser cohort MSN capstone

First Advisor

Sara Horton-Deutch



Problem: Hospital acquired pressure injures (HAPI) are potentially preventable but frequently occurring events in hospitalized patients. Pressure injuries can occur because of prolonged pressure and in combination with shear and friction forces. HAPI negatively impacts a patient’s quality of life. HAPI also increases the hospital’s financial burden and increases the patient’s length of stay.

Context: The 52-bed medical surgical, telemetry, COVID, unit is one of several unis within a hospital setting. The unit is challenged with the management of HAPIs. The staff are challenged with documenting and escalating the findings, and with finding a second nurse to assist with the two-nurse skin check.

Intervention: A quality improvement project was developed to address the pressure injuries and improve patient outcome. The project’s interventions are aimed at providing education and training to the staff early identification, early escalation, and accurate documentation.

Measures: Three measures were implemented that included early escalation through the use of an escalation algorithm, use of the LDA Avatar for documentation, and designation of a second nurse to assist in performing the two-nurse skin assessment.

Results: Streamlining HAPI prevention strategies led to early recognition and implementations of the appropriate prevention strategies.

Conclusion: Standardizing practices led to decreased pressure injuries on the unit. The unit HAPI incidents decreased by 80% during the 4-month project.

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