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


MSN project

First Advisor

Caitlin Heberer


This project was conducted at a level one trauma center, acute care hospital consisting of 459 beds. With more patients than wound care nurses, hospital-acquired pressure injuries (HAPIs) have become a significant problem for this hospital. A gap between reporting in the Safety and Quality Information System (SQIS) and the reporting that takes place in electronic health record (EHR) with wound care consults has been observed. A root cause analysis (RCA) was used to identify discrepancies. The accurate collection of data was identified as paramount providing information necessary to create improvements and lower the occurrence of HAPIs. The conceptual framework which guided this project to decrease the incidence of inaccurate HAPI documentation was the PDSA model/cycle. The Lewin Change Model was applied as the leadership theory. The cost of one HAPI is $14,506 and can potentially cost the hospital $2,088,864 per year. With the proper education to prevent HAPIs from occurring, the medical center can save on average $1,044,432 per year. The plan is to educate nurses on the prevention, correct staging, and proper documentation of HAPIs. Using process and balance measures, the team can study the effectiveness of the interventions. Additionally, nurses who attended educational sessions completed pre and post tests to assess their knowledge which was then compared through a bar chart. With all these efforts, expected outcomes are to sustain a 50% decrease in HAPIs at this hospital.